t\Cli 


MANUAL 


PHYSICAL  DIAGNOSIS. 


TYSON. 


BY  THE  SAME  AUTHOR. 


THE  PRACTICE  OF  MEDICINE.  A  Text-Book  for  Physicians 
and  Students,  with  Special  Reference  to  Diagnosis  and  Treat- 
ment. Second  edition.  Thoroughly  Re%-ised  and  Enlarged. 
ICO  Illustrations.     Octavo. 

Cloth,  $5.50;    Leather,  S6.50;   Half  Russia,  S7.50 

"  This  work  not  only  represents  the  work  of  a  practitioner  of  great  experience, 
but  of  a  careful  culling  of  the  facts  set  forth  in  contemporary  literature  by  one 
who  well  understands  the  art  of  separating  the  true  from  the  false." — The  Jo-ur- 
nalqfihe  American  Medical  Assoczatzon,  Chicag-o. 

"  Represents  the  outcome  of  much  well-directed  labor,  and  constitutes  a 
reliable  and  useful  text-book." — T/te  London  Lancet. 

"  Few  teachers  in  the  country  can  claim  a  longer  apprenticeship  in  the  labor- 
atory- and  at  the  bedside,  none  a  more  intimate  acquaintance  with  students,  since 
in  one  capacity  or  another  he  has  been  associated  with  the  University  of  Penn- 
sylvania and  the  Philadelphia  Hospital  for  nearly  thirty  years.  Moreover,  he 
entered  medicine  through  the  portal  of  pathologj-,  a  decided  advantage  in  the 
writer  of  a  text-book.  .  .  .  It  is  a  piece  of  good,  honest  work,  carefully  con- 
ceived and  conscientiously  carried  out." — The  University  Medical  Magazine. 

GUIDE  TO  THE  EXAMINATION  OF  URINE.  Ninth  Edition. 
For  the  use  of  Physicians  and  Students.  With  a  Colored 
Plate  and  48  other  Illustrations.     Completely  Revised.     i2mo. 

Cloth,  31.25 

"  It  is  without  exception  the  best  work  of  its  kind  in  the  English  language." 
— Bosto?t  Medical  and  Surgical  Jouriial. 

"  The  subject-matter  of  which  it  treats  is  complete  without  being  verbose;  it 
is  concise,  thorough,  and  up  to  date.  It  is  a  volume  that  should  be  in  the  hands 
of  every  medical  student,  and  in  the  library  of  every  practitioner." — Buffalo 
Medical  and  Surgical  Joitrnal. 

THE  CELL  DOCTRINE:  Its  History  and  Present  State,  together 

with  a  copious  Bibliography  of  the  Subject.     With  a  Colored 

Plate  and  other  Illustrations.     Second  Edition.     Cloth,  31.50 

"  The  first  edition  of  Dr.  Tyson's  work  appeared  in  1870,  and  at  once  received 
the  favorable  reception  from  the  profession  to  which  it  was  entitled  by  its 
merits.  The  present  edition  shows  an  increase  in  size  of  about  fifty  pages,  and 
almost  every  page  furnishes  evidence  of  careful  revision." — American  Journal 
of  the  Medical  Sciences. 

These  Prices  are  Xet. 

P.  BLAKISTON'S  SON  &  CO.,  PHILADELPHIA. 


MANUAL 


PHYSICAL  DIAGNOSIS 


FOR  THE   USE  OF 


STUDENTS  AND  PHYSICANS. 


JAMES  TYSON,  M.  D., 

PROFESSOR    OF     CLINICAL     MEDICINE    IN    THE    UNIVERSITY   OF    PENNSYLVANIA 
AND    PHYSICIAN   TO   THE   UNIVERSITY   HOSPITAL;     PHYSICIAN    TO    THE 
PHILADELPHIA    HOSPITAL;     FELLOW   OF    THE   COLLEGE   OF   PHYSI- 
CIANS  OF    PHILADELPHIA  ;     MEMBER    OF   THE   ASSOCIATION 
OF    AMERICAN    PHYSICIANS,    ETC. 


THIRD   EDITION,  REVISED   AND    ENLARGED, 
WITH  COLORED  AND  OTHER  ILLUSTRATIONS. 


PHILADELPHIA  : 
P.  BLAKISTON'S  SON  &  CO 

IOI2     WALNUT     STREET, 

I  goo. 


Copyright,  1898,  by  James  Tyson,  M.  D. 


Press  of 

TTickersham  Printing  Co,, 

Lancaster,  Pa. 


PREFACE  TO  THIRD  EDITION. 


Advantage  has  been  taken  of  the  opportunity  afforded 
by  the  demand  for  another  edition  of  this  manual  to 
improve  it  and  extend  it  as  far  as  consistent  with  the 
original  purposes  of  the  book.  The  section  on  the 
examination  of  blood  has  been  enlarged,  so  as  to  meet 
more  completely  the  requirements  of  a  modern  blood 
examination.  The  same  may  be  said  of  the  section  on 
the  chemical  examination  of  gastric  contents.  A  num- 
ber of  new  illustrations  have  been  introduced,  together 
with  other  additions  of  a  minor  character,  all  intended 
to  add  to  the  accuracy  and  usefulness  of  this  book.  I 
am  indebted  to  Prof.  A.  C.  Abbott  and  Dr.  Alfred 
Stengel  for  assistance  in  the  technique  of  the  blood 
and  bacteriological  examinations. 
1506  Spruce  Street, 
June  I,  i8g8. 

(v) 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/manualofphysicalOOtyso 


TABLE  OF  CONTENTS. 


PAGE 

General  Considerations, 9 

Regions  or  Spaces  of  the  Chest,     .    . 11 

Medical  Anatomy  of  Thorax, 15 

Inspection  and  Mensuration, 26 

Palpation, 32 

Percussion, 34 

Percussion  of  the  Normal  Chest, 45 

Abnormal  Percussion  Lung  Sounds, 52 

Auscultation, 61 

Auscultation  of  the  Normal  Lung, 65 

Abnormal  Modifications  of  Breathing  Sounds,  ....  68 

Auscultation  of  the  Normal  Voice, 75 

New  or  Adventitious  Sounds, 78 

Physical  Signs  of  Abnormal  States  of  the  Lungs,    ...  83 

Acute  Bronchitis, 83 

Chronic  Bronchitis, 84 

Emphysema  of  Lungs, 85 

Interlobular  Emphysema, 88 

Spasmodic  Asthma, 88 

Pulmonary  Tuberculosis, 89 

Catarrhal  Phthisis,      . 94 

Fibroid  Phthisis, 94 

Miliary  Tuberculosis, 95 

Pneumonia, 96 

Croupous,   . 96 

( vii ; 


Vlll  TABLE   OF    CONTENTS. 

PAGE 

Pneumonia.  Catarrhal,  .....            lOO 

Embolic, •    •    •  lOl 

Pulmonary  CEdema, I02 

Collapse  of  the  Lung, 102 

Cancer  of  the  Lung, 1O3 

Pleurisy   .    .             103 

Chronic  Pleurisy,    ... 107 

Pneumothorax, Ill 

Physical  Examination  OF  THE  Heart, 113 

Anatomical  Relations  of  the  Heart, 1 13 

Percussion  and  Auscultation  of  the  Normal  Heart,     .    .  116 

Abnormal  Modification  of  the  Heart  Sounds,     ....  124 

Organic  Murmurs, 128 

Functional  Murmurs, 138 

Vascular  Murmurs, 141 

The  Sphygmograph  in  Diagnosis, 144 

The  Cardiograph  in  Diagnosis, 152 

Physical  Signs  OF  Different  Forms  OF  Heart  Disease,    .  156 

Mitral  Insufficiency, 156 

Mitral  Stenosis, 159 

Mitral  Insufficiency  and  Stenosis, 162 

Aortic  Stenosis, 162 

Aortic  Insufficiency, 165 

Aortic  Stenosis  and  Insufficiency, 168 

Tricuspid  Insufficiency,      168 

Tricuspid  Stenosis,     , 171 

Pulmonary  Stenosis, ...  172 

Pulmonary  Regurgitation,      ....             173 

Congenital  Defects, 173 

Relative  Frequency  and  Danger  of  Valvular  Defects,    .  174 

Acute  Endocarditis, 179 

Pericarditis, 180 

Diseases  of  the  Myocardium, 181 

Thoracic  Aneurysm, 188 


TABLE   OF   CONTENTS.  IX 

PACK 

Physical  Examination  of  the  Abdomen, 197 

Inspection, 199 

Palpation, 201 

Percussion, 204 

Auscultation, 209 

Appendix — 

Examination  of  Blood, 212 

Estimation  of  Blood  Corpuscles, 212 

Estimation  of  Haemoglobin,      220 

Preparation  of  Stained  Films, 222 

Widal  Test  for  Typhoid  Fever, 224 

Examination  of  Sputum,    . 226 

Staining  of  Tubercle  Bacilli, 227 

The  Pneumococcus, 229 

Bacillus  of  Diphtheria, 232 

Bacillus  of  Typhoid, 233 

Bacillus  of  Cholera, 234 

Bacillus  of  Syphilis, 234 

Bacillus  of  Gonorrhcea, 234 

Chemical  Examination  of  Gastric  Contents, 235 

To  Test  Eate  of  Absorption  from  Stomach, 252 

To  Test  Motor  Functions  of  Stomach,     .            ....  233 

To  Test  Capacity  of  Stomach, 254 

The  Roentgen  Ray  in  Diagnosis, 255 

The  Making  of  an  Autopsy, 258 

Order  of  Examination  OF  Patient, 271 

French  Weights  and  Measures,      273 

Index, 275 


LIST  OF  ILLUSTRATIONS. 


PLATFS  PAGE 

1.  Illustrating  different  forms  of  the  malarial  organism,  with 

their  stages  of  development, 212 

2.  Differential  staining  of  the  blood, 223 


1.  Regions  ot  the  thorax,  anterior  aspect, 12 

2.  Regions  of  the  chest,  posterior  aspect,  14 

3.  Anterior  view  of   the  organs  of   the  chest  and  abdominal 

cavity, 17 

4.  Posterior  view  of   the  organs  of  the  chest  and  abdominal 

cavity, 21 

5.  Transverse  section   of  healthy  adult  chest  at    level  sterno- 

xiphoid  articulation,  .    .         28 

6.  Pigeon-breast,  child  of  seven  years, 29 

7.  Rickety  chest, 30 

8.  Percussion  hammer  of  plexor, 34 

9.  Ivory  pleximeter, 34 

10.  Sansom's  pleximeter,      34 

11.  The  phonendoscope, 37 

12.  Absolute  and  relative  percussion  dulness  of  liver  and  heart,  49 

13.  Gerhardt's  change  of  note,  57 

14.  Hawksley's  stethoscope, 62 

15.  Sansom's  binaural  stethoscope, 63 

16.  Simpler  fonn  of  Sansom's  binaural  stethoscope,     ....  63 

17.  Valentine's  binaural  stethoscope, .  64 

(xi) 


XU  LIST    OF   ILLUSTRATIONS. 

FIG.  PAGE 

1 8.  Bilateral  enlargement  in  emphysema 86 

19.  Position  of  heart  in  relation  to  ribs  and  sternum,    ....  114 

20.  Absolute  and  relative  percussion  dulness  of  liver  and  heart,   117 

21 .  Diagram  showing  the  location  of  cardiac  valves  and  points 

of  maximum  intensity  connected  wdth  them, 121 

22.  Mitral  sj'stolic  murmur,  propagated  in  front, 129 

23.  Mitral  systolic  murmur,  propagated  behind, 130 

24.  Mitral  presystolic  murmur  (Hutchison  and  Rainy),    .    .    .  132 

25.  Aortic  systolic  murmur  and  its  propagation, 134 

26.  Aortic  diastolic  murmur  and  its  seats  of  propagation  J    .    ,  135 

27.  Normal  sph3-gmogram, 146 

28.  Sphygmogram  showing  prolonged  arterial  tension,     .    .    .  148 

29.  Anacrotic  pulse-cur\-es  from  the  radial  arterj', 148 

30.  Tracing  of  pulse  of  aortic  regurgitation, 149 

31.  Tracing  from  case  of  prolonged  arterial  tension,  showing 

dicrotic  wave, 150 

32.  Bigeminal  pulse, ...  151 

33.  Trigeminal  pulse, 151 

34.  Normal  cardiac  apex  tracing, 153 

35.  Tracing  pulse  of  mitral  insufficiency, 158 

36.  Tracing  of  pulse  in  mitral  stenosis, 160 

37.  Pulse  tracing  of  aortic  stenosis, 163 

38.  Tracing  of  pulse  of  aortic  regurgitation, 166 

39.  Combined  aortic  and  mitral  sj-stolic  murmurs, 169 

•  40.  Drawing  showing  regions  of  the  abdomen, 198 

41.  Hsemocytometer  pipette, 214 

42.  Thoma-Zeiss  counting  slide, 215 

43.  Groups  of  sixteen  small  squares,  making  one  large  square 

of  the  Thoma-Zeiss  c}1:ometer,  magnified, 216 

44.  The  Thoma-Zeiss  ruled  shde  focused  for  ten  and  twelve 

squares,       217 

45.  Hsemoglobinometer  of  Fleischl, 220 

46.  "  Seal  Fin  "  deflexion  of  the  hand  in  a  case  of  protracted 

arthritis  deformans, 257 


MANUAL 


PHYSICAL  DIAGNOSIS 


GENERAL  CONSIDERATIONS. 

The  term  physical  diagnosis  strictly  defined  would 
include  the  diagnosis  or  investigation  of  disease  by  the 
aid  of  all  the  special  senses,  but  practically  it  is  con- 
fined to  eliciting  such  information  as  can  be  furnished 
by  vision,  touch,  and  hearing,  whence  come  the  terms 
inspection.,  palpation,  and  nusailtation.  The  information 
acquired  by  hearing  is  further  subdivided  into:  ist. 
That  gained  by  listening  directly  to  the  various  normal 
sounds  and  their  modifications  as  produced  by  morbid 
states,  and  to  certain  new  sounds  produced  by  such 
states.  2d.  Information  gained  by  striking  or  percus- 
sing the  part  to  be  investigated.  Hence,  too,  the  words 
auscultation  and  percussion  are  constantly  used  in  asso- 
ciation. 

The  information  furnished  by  inspection  is  also  ren- 
dered   more    accurate    by    measuring   or    mensuration, 

9 


10  PHYSICAL    DLA.GXOSIS. 

when  this  can  be  applied.  Thus  constituted,  physical 
diagnosis  is  applied  to  any  portion  of  the  body,  but  it 
is  more  especially  in  the  study  of  diseases  of  the 
thoracic  and  abdominal  contents,  and  particularly  the 
former,  that  it  is  useful.  The  phenomena  thus  learned 
are  known  as  physical  signs.  The  use  of  the  term 
"  physical ''  is  based  upon  the  fact  that  it  is  through 
alterations  in  the  physical  properties  of  the  tissue  or 
organ  investigated  that  information  is  obtained,  such  as 
the  shape,  density,  transparency.  On  the  other  hand, 
in  its  usual  application  there  is  a  limitation  inconsistent 
with  strict  accuracy.  Thus  there  is  no  more  accurate 
means  of  recognizing  physical  states  than  by  ther- 
mometry, yet  thermometry  is  not  one  of  the  measures 
included  under  physical  diagnosis. 

It  is  very  true  that  a  knowledge  of  physical  signs 
cannot  be  acquired  from  books  and  must  be  learned  at 
the  bedside;  but  we  may  record  their  import  and 
significance  in  the  recognition  of  disease  and  render 
somewhat  easier  their  study.  To  this  end  is  indispens- 
able a  familiarity  with  the  physical  condition  of  the 
organs  o£  the  body  in  a  state  of  health.  This,  too,  can 
only  be  learned  on  the  living  subject  by  giving  the 
student  an  opportunity  to  listen  until  he  is  thoioughly 
familiar  with  the  normal  breathing-  and  heait-sounds, 
to  observe  the  normal  shape  and  configuration  of  the 
body,  and  to  learn  the  percussion  note  characteristic  of 
different  regions  over  important  organs,  as  ihe  heart, 
lungs,  and  various  abdominal  viscera.  Such  a  study  of 
the  situation  of  internal  organs  in  relation  to  external 


REGIONS   OR   SPACES   OF   THE    CHEST.  II 

parts,   for    the    purposes   of    the    physician,  constitutes 
medical  anatomy. 

The  attainment  of  the  objects  of  physical  diagnosis  is 
greatly  facilitated  by  mapping  out  the  body  into  certain 
spaces  or  areas,  of  which  we  consider  first  the 

REGIONS   OR   SPACES   OF  THE   CHEST. 

Starting  with  the  clavicle  and  sternum  as  land- 
marks in  physical  examination,  above  each  clavicle,  in 
health,  is  usually  a  slight  depression  known  as  the 
supraclavicular  fossa,  and  above  the  sternum 
another  known  as  the  suprasternal  notch.  Below 
each  clavicle  is  the  infraclavicular  space,  which  is 
somewhat  arbitrarily  bounded  below  by  the  upper  edge 
of  the  3d  rib  and  adjacent  cartilage,  internally  by 
the  edge  of  the  sternum,  and  externally  by  the  base  of 
the  shoulder  or  a  line  drawn  vertically  from  the  inner 
end  of  the  outer  fourth  of  the  clavicle.  Below  the 
clavicle,  as  well  as  above,  in  health,  is  usually  a  slight 
depression.  All  these  depressions  or  spaces  are  liable 
to  become  deeper  in  emaciation,  and  are  less  conspicu- 
ous in  fat  persons.  Below  the  upper  edge  of  the  3d  rib 
is  the  mammary  region,  bounded  internally  by  the 
edge  of  the  sternum,  externally  by  the  above  described 
vertical  line,  and  below  by  the  upper  margin  of  the 
6th  rib.  Nearly  in  the  centre  of  the  mammary  region 
is  the  nipple,  which  in  males  and  young  girls  is  just 
below  the  4th  rib.  A  line  drawn  vertically  through  it 
is  known  as  the  mammillary  line.     The  mid-cla- 


Fig.  I. — Regions  of  the  Thorax,  Anterior  Aspect. 

The  figure  is  taken  from  a  photograph  of  a  living  subject  on  which  the  ribs 
were  made  more  distinct  bs  chalk.  While  the  chest  is  fairly  typical,  the  dis- 
tance between  the  end  or  the  ensiform  cartilage  and  the  umbilicus,  which 
varies  in  different  individuals,  is  perhaps  longer  than  the  average  in  this  case. 


REGIONS    OR    SPACES    OF    THE    CHEST.  1 3 

vicular  line  coincides  with  the  mammillary  line  when 
the  nipple  is  in  its  typical  situation,  and  is  therefore  a 
better  term.  Below  the  mammary  region,  as  far  as  the 
edge  of  the  thorax,  is  the  inframammary  region. 
In  the  centre  of  the  thorax  anteriorly  is  the  sternum, 
bounded  by  its  notch  above  and  the  end  of  the  ensiform 
cartilage  below.  It  is  divided  into  the  upper  sternal 
region,  extending  as  far  as  a  line  drawn  along  the  upper 
edge  of  the  3d  cartilage,  and  the  lower  sternal,  in- 
cluding the  remainder  of -the  bone.  Laterally  are  the 
axillary  and  the  infra-axillary  regions,  the  former 
above  and  the  latter  below  a  line  continuous  transversely 
with  the  lower  border  of  the  mammary  region  (6th  rib)  ; 
bounded  in  front  by  the  external  border  of  the  mam- 
mary and  inframammary  regions,  and  behind  by  a  line 
drawn  vertically  downward  from  the  insertion  of  the 
posterior  fold  of  the  axilla.  The  infra-axillary  region 
extends  downward  to  the  edge  of  the  thorax. 

Posteriorly  are  the  scapular  regions,  including  the 
supraspinous  fossa  and  the  infraspinous  fossa 
of  each  scapula,  sufficiently  indicated  by  their  names; 
the  interscapular  region,  and  the  subscapular  or 
infrascapular  regions.  The  interscapular  region  is  in- 
cluded between  the  scapulae  posteriorly  and  bounded 
below, by  a  line  drawn  through  theangles  of  these  bones 
m  the  position  assumed  by  them  wheB;-,t|j-e;  arms  are 
hanging  at  the  side.  Such  line  usually  crosses  the  7th 
rib.  The  infrascapular  regions  are  bounded  above  by 
the  line  just  described,  below  by  the  edge  of  the  thorax, 


14 


PHYSICAL    DL4GNOSIS. 


Fis.  2. — Regions  of  the  Chest,  Posterior  Aspect. 


MEDICAL    ANATOMY    OF    THE    THORAX.  1 5 

and  extend  from  the  median  line  to  the  posterior  axil- 
lary line  on  each  side. 

In  addition  to  the  mammillary  line,  are  lines  drawn 
vertically  down  the  middle  of  the  axilla  and  through 
the  angle  of  the  scapula  behind,  called  the  mid-axil- 
lary and  mid-scapular  lines — also  landmarks  useful  in 
description.  The  parasternal  line,  frequently  used, 
is  a  vertical  line  drawn  midway  between  the  edge  of  the 
sternum  and  the  mammillary  line. 


MEDICAL  ANATOMY  OF  THE  THORAX. 

For  the  intelligent  study  of  the  physical  diagnosis  of 
the  chest,  it  is  important  that  the  student  should  know 
what  viscera  or  parts  of  viscera  are  contained  in  the 
areas  just  mapped  out.      (See  Figs.  3  and  4.) 

1.  In  X\\&  supraclavicular  xtg\Q)\\  is  contained  the  apex 
of  the  lung  (4,  10,  Fig.  3),  which  rises  above  the  upper 
border  of  the  clavicle  to  the  extent  of  ^  inch  to  i^ 
inches  and  even  two  inches,  varying  in  different  per- 
sons. It  is  rather  toward  the  inner  end  of  the  clavicle. 
One  or  the  other  apex  is  usually  a  little  higher  than  its 
fellow,  the  left  more  frequently.  The  apex  of  the  lung 
is  crossed  by  the  subclavian  vessels  in  the  first  part  of 
their  course.  In  the  subclavicular  fossa  near  the  outer 
border  of  the  sternomastoid  muscle,  and  about  one  inch 
above  the  clavicle,  the  beating  of  the  subclavian  artery 
can  be  felt.  In  this  hollow,  too,  is  the  termination  of 
the  external  jugular  vein. 

2.  Behind  the  clavicle,  in  the    clavicular   region,    is 


l6  PHYSICAL   DLA.GXOSIS. 

also  found  the  lung,  but  the  ist  and  2d  ribs  are  inter- 
posed between  the  clavicle  and  the  lung,  so  that  no 
typical  lung  note  on  percussion  can  be  expected  in  that 
situation.  Behind  the  inner  end  of  the  clavicle  is  the 
commencement  of  the  innominate  vein  ;  behind  this, 
on  the  left  side,  the  common  carotid  ;  to  the  outside  of 
,  this  the  left  subclavian  artery ;  and  on  the  right  side 
behind  the  sternoclavicular  joint,  the  bifurcation  of  the 
innominate. 

3.  The  infraclavicular  regions  are  occupied  almost 
purely  by  lung  stmcture.  The  superior  cava  extends 
slightly  beyond  the  right  t^g^  of  the  sternum  in  this 
region,  the  pulmonary  artery  somewhat  more  to  the  left 
of  the  left  edge  of  the  stemum.  The  left  auricle  is  in 
the  2d  intercostal  space  and  extends  to  the  left  para- 
sternal line,  being  covered  by  the  edge  of  the  lung. 

4.  The  structures  occupying  the  mammary  regions 
differ  considerably  on  the  two  sides.  The  right  side  is 
the  simpler.     It  is  occupied  mainly  by  lung.     At  least 

Fig.  3. — Anterior  View  of  the  Organs  of  the  Chest  and  Abdominal 
Cavity  with  Reference  to  their  Relations  to  the  Skeleton  and  the 
Boundaries  of  the  Stomach. 

I.  Larynx.  2.  Thyroid  gland.  ,  3.  Trachea.  4.  Right  lung-apex.  5.  L^pper 
lobe.  6.  Middle  lobe.  7.  Lower  lobe,  of  right  lung.  8.  L^pper,  9.  Lower 
interlobular  boundary  of  the  right  lung.  10.  Apex,  11.  Upper  lobe,  12. 
Lingual  process  of  the  left  lung.  13.  Cardiac  boundary  of  the  anterior 
border  of  the  left  lung.  14.  Portion  of  the  anterior  aspect  of  the  pericardium 
covered  by  the  cardiac  pleura.  15.  Portion  of  same  uncovered  by  diaphragm. 
Site  for  paracentesis.  t6.  Anterior  border  of  the  right  mediastinum.  17. 
Anterior  border  of  the  left  mediastinum.  18.  L'pper  or  true  border  of  the  liver 
partially  covered  by  lung.  19.  Right  lobe  of  the  liver.  20.  Quadrate  lobe  of 
the  liver.  21.  Left  lobe  of  the  liver.  22.  Gall  bladder.  23.  Cardiac  end  of 
the  stomach.  24.  Stomach  cul-de-sac  partially  covered  \>y  lung.  25.  Pj'loric 
end  of  the  stomach.  26.  Larger  curvature  of  the  stomach  (right  gastro- 
epiploic artery).  27.  Transverse  colon.  28.  Ascending  colon.  29.  Descend- 
ing colon.  30.  Vermiform  appendix.  31.  Small  intestine.  32.  Bladder. — 
{After  Luschka,  slightly  modified.) 


1 8  PHYSICAL    DLA.GNOSIS. 

lung  only  reaches  the  surface  in  this  space.  The  dome- 
shaped  right  lobe  of  the  liver  projects  into  a  correspond- 
ing space  in  the  under  surface  of  the  right  lung  as  far  as 
the  4th  interspace.  To  the  right  of  the  sternum  is  the 
right  auricle,  behind  the  3d  costal  cartilage,  the  3d  in- 
terspace, the  4th  costal  cartilage,  and  4th  interspace, 
and  extending  almost  to  the  right  parasternal  line,  but 
covered  by  lung.  The  right  ventricle  extends  very 
slightly,  if  at  all,  by  the  outer  inferior  angle  of  its  base, 
from  behind  the  sternum  into  the  6th  interspace. 

The  left  mammai-y  region  is  occupied  aluiost  as  far  as 
the  mid-cla\acular  line  b}'^  the  heart,  including  portions 
of  the  right  and  left  ventricle.  The  cardiac  line  is  an 
oblique  one  beginning  at  or  near  the  junction  of  the  left 
parastemal  line  with  the  lower  border  of  the  2d  rib  and 
thence  downward  and  outward  to  the  apex  formed  by 
the  left  ventricle  in  the  5  th  interspace  an  inch  below 
and  within  the  nipple.  The  upper  portion  of  this  area 
is  covered  by  lung,  leaving  only  a  tongue-shaped  por- 
tion of  the  heart  uncovered  between  the  4th  and  6th 
ribs.  Between  the  4th  and  5th  ribs  (at  15,  Fig.  3),  near 
the  sternum,  is  a  spot  of  the  pericardium  uncovered  by 
the  diaphragm,  which  is  the  usual  site  for  paracentesis 
of  the  pericardium.  The  remainder  of  the  left  mam- 
rcary  region  is  occupied  by  lung. 

5.  Th^  ififramamfjiary  regions  d\&eT  ev&n  more  on  the 
two  sides  in  the  structures  comprehended  in  them.  This 
region  on  the  7-ierht  side  mainly  covers  the  liver  separated 
from  the  chest-wall  by  the  diaphragm,  the  dome  of 
which  reaches  its  highest  point  in    the  4th  interspace 


:medical  anatomy  of  the  thorax.  19 

within  the  mammillar_y  line.  The  lung  extends  down 
to  the  6th  rib.  The  lower  border  of  the  liver  in 
health  just  reaches  the  edge  of  the  ribs  at  the  mid -cla- 
vicular line,  and  then  extends  obliquely  upward  toward 
the  left,  Glossing  the  median  line  usually  at  one-third 
the  distance  between  the  ensiform  cartilage  and  the 
umbilicus,  and  reaching  the  left  border  of  the  thorax  at 
or  near  the  left  parasternal  line.  The  lower  edge  of 
the  liver  varies  somewhat  in  healthy  individuals,  and 
descends  below  the  ribs  with  deep  inspiration. 

The  left  inframamma?-y  region  includes  the  anterior 
part  of  the  lower  lobe  of  the  left  lung,  the  left  lobe  of 
the  liver,  the  cardiac  end  of  the  stomach,  varying 
degrees  of  distension  of  the  latter  organ  producing 
considerable  variation  in  the  percussion  boundaries  of 
these  organs. 

Between  the  inframammary  regions  is  the  epigastrmm 
in  abdominal  topography.  In  the  right  half  of  the 
epigastrium  is  the  quadrate  lobe  of  the  liver,  the  gall 
bladder,  the  pyloric  end  of  the  stomach  at  a  point  mid- 
way between  the  ensiform  cartilage  and  the  parasternal 
line,  behind  the  liver  and  adjacent  to  the  gall  bladder. 
The  fundus  of  the  gall  bladder  can  sometimes  be  felt  at 
the  edge  of  the  liver.  In  the  left  half  of  the  epigastrium 
is  the  left  lobe  of  the  liver  and  lower  median  part  of  the 
stomach. 

6.  The  suprasternal  notch  is  solely  occupied  by  the 
trachea  in  health,  but  is  often  encroached  upon  by  a 
dilated  aorta,  or  aoita  pushed  up  by  a  hypertrophied 
heart. 


20  PHYSICAL   DIAGNOSIS. 

7.  The  tipper  sternal  region  under  the  manubrium  is 
occupied  by  the  trachea,  which  bifurcates  at  the  junction 
of  the  ist  and  2d  bone,  by  a  part  of  the  superior  cava, 
the  arch  of  the  aorta,  the  left  innominate  vein,  which 
joins  its  fellow. to  form  the  superior  cava  just  below  the 
cartilage  of  the  ist  rib,  close  to  the  right  edge  of  the 
sternum  ;  also  by  a  part  of  the  pulmonary  artery.  The 
upper  and  central  part  of  this  region  is  uncovered  by 
lung. 

8.  The  lower  sternal  region  contains  a  part  of  the 
aorta,  a  portion  of  the  right  auricle,  much  of  the  right 
ventricle,  beginning  opposite  the  4th  caitilages,  and 
behind  this  the  left  ventricle.  The  edges  of  the  two 
lungs  unite  through  the  upper  part  of  this  region  in  the 
middle  line,  the  left  diverging  at  the  4th  rib  where  the 
uncovered  tongue-shaped  piece  of  the  heart  commences. 
The  primary  bronchi  are  found  diverging  at  the  upper 
part  of  this  region,  where  they  penetrate  the  lung.  The 
right,  larger  and  shorter,  passes  downward  on  the  level 
of  the  4th  dorsal  vertebra ;  the  left,  longer  and  smaller, 
downward  and  outward  to  the  level  of  the  5th  dorsal 
vertebra. 

9.  The  scapular  regions  cover  the  lung,  the  incisure 
between  the  upper  and  lower  lobes  passing  obliquely 
downward  under  the  bone  from  the  upper  edge  of  the 
5  th  rib  behind,  to  between  the  5th  and  6th  ribs  laterally. 

10.  The  interscapular  region  in  its  central  portion  is 
occupied  by  dorsal  vertebrae,  in  front  of  which  is  the 
trachea,  bifurcating  at  the  4th,  whence  its  primary 
bronchi  extend  downward  and  outward  surrounded  by 
lung  structure. 


MEDICAL  ANATOMY  OF  THE  THORAX. 


Fig.  4. — Posterior  View  ok  the  Organs  of  the  Chest  and 
Abdominal  Cavity. 

T.  Upper  lobe.  2.  Lower  lobe  of  left  lung.  3.  Interlobular  boundary  between 
them.  4.  Upper  lobe  of  right  lung.  6.  Middle  lobe  of  the  right  lung.  7. 
Line  between  upper  and  middle  lobes  of  the  right  lung.  9.  Stomach  demarked 
by  a  dark  line.  10.  Spleen  in  its  relation  to  the  lung  in  expiration,  with  the 
kidney  showing  behind  and  below  it.  11.  Left  kidney.  12.  Horizontal  upper 
part  of  the  duodenum.  13.  Descending  portion  of  the  duodenum.  14.  Hori- 
zontal lower  part  of  the  duodenum.  15.  Duodeno-jejunal  flexure.  ■i5.  Liver, 
zo    Pancreas.     21.  First  dorsal  vertebra. — {After  Luschka.) 


2  2  PHYSICAL    DIAGNOSIS. 

11.  The  infra-  or  subscapular  regions,  extending  from 
the  angles  of  the  scapulae  to  the  edge  of  the  thorax,  in- 
clude on  the  right  side  lung  as  far  as  the  loth  rib  in  the 
mid-scapular  line.  Below  this  is  the  complemental 
pleural  space  (see  p.  24)  filled  by  lung  only  in  deep  in- 
spiration, as  far  as  the  nth  rib,  where  the  lower  border 
of  the  liver  is  met.  The  thick  lumbar  muscles  separate 
the  integuments  to  the  right  of  the  vertebrae  from  the 
upper  end  of  the  right  kidney,  forward  of  which  is  the 
pyloric  orifice  of  the  stomach.  The  upper  end  of  the 
right  kidney  is  covered  by  the  nth  interspace  and  the 
short  12th  rib.  On  the  left  side  there  is  pure  lung  tissue 
as  far  as  the  loth  rib,  whence  it  dips  down  in  deep  inspira- 
tion into  the  complemental  pleural  space  between  the 
thoracic  wall  and  that  part  of  the  diaphragm  covering 
the  spleen,  which  extends  from  the  9th  to  the  nth  ribs 
inclusive.  A  small  portion  of  lung  tissue  is  interposed 
between  the  posterior  edge  of  the  spleen  and  the  loth 
dorsal  vertebra.  The  cardiac  orifice  of  the  stomach  is 
on  the  left  side  about  opposite  to  the  body  of  the  9th 
dorsal  vertebra.  Beneath  the  nth  rib  is  the  upper  end 
of  the  kidney,  which  extends  a  little  higher  on  the  left 
side  than  the  right.  The  left  end  of  the  pancreas  is 
close  to  the  spinal  column  in  the  nth  interspace  and 
under  the  root  of  the  12th  rib. 

12.  The  axillary  regions  on  both  sides  are  occupied 
with  lung  structure,  a  part  of  the  upper  lobe  of  each 
lung. 

13.  The  infra- axillary  regions  are  again  more  com- 
plex in  the  structures  they  cover,     On  the   right  side 


MEDICAL    ANATOMY    OF    THE    THORAX.  23 

there  is  lung  as.  far  as  the  9th  rib  in  the  mid-axillary 
Une;  below  this  is  liver  to  the  nth  rib,  or  edge  of  the 
thorax  in  this  line. 

On  the  left  side  there  is  lung  as  far  as  the  9th  rib 
in  the  mid-axillary  line.  Below  this  is  the  spleen, 
which  extends  to  the  nth  rib  inclusive,  or  edge  of 
the  thorax  at  this  situation.  The  cardiac  end  of  the 
stomach,  especially  when  dilated,  is  apt  to  protrude  into 
the  infra-axillary  region  and  to  influence  the  percussion 
note. 

The  Borders  of  the  Lungs. — It  is  to  be  remem- 
bered that  the  anatomical  outlines  just  described  are  of 
themselves  rather  approximate,  and,  furthermore,  that 
they  do  not  necessarily  coincide  with  the  percussion 
boundaries  of  the  same  organ,  as  in  many  situations 
portions  of  lung  protrude  between  the  organs  and  the 
surface  and  produce  a  modification  of  the  note  peculiar 
to  such  organs,  which  modification  is  the  relative  or 
deep-seated  dulness  of  the  organs.  It  is  therefore  use- 
ful also  to  know  the  correct  anatomical  boundaries  of 
the  lungs  as  a  whole  in  relation  to  the  landmarks  given  : 

In  front  the  lungs  extend  above  the  clavicles  from 
Yo  inch  to  1J-3  inches  or  more;  behind  as  far  as  a 
line  drawn  through  the  apex  of  1  he  spinous  process  of 
the  7  th  cervical  vertebra.  Downward  and  adjacent  to 
the  sternum,  the  right  lung  extends  to  the  neighbor- 
hood of  the  6th  cartilage,  the  left  to  the  4th;  in 
the  mid-axillary  line  both  extend  to  the  lower  border 
of  the  7th  rib,  in  the  mid-scapular  line  to  the  loth 
rib,  and  near  the  spinal  column  to  the  nth  rib.     On 


24  PHYSICAL    DLA.GNOSIS. 

the  left  side  at  the  inner  end  of  the  4th  cartilage  the 
lung  diverges  from  under  the  breast  bone  obliquely 
behind  the  4th  cartilage  through  the  4th  intercostal 
space  and  again  turns  toward  the  sternum  behind 
the  5th  costal  cartilage,  but  at  the  6th  cartilage  again 
turns  outward.  By  this  divergence  is  formed  the  tongue- 
shaped  indentation  of  the  lung  border,  by  which  a  por- 
tion of  the  heart  is  uncovered.  Behind  the  sternum, 
from  the  2d  to  the  4th  cartilage,  the  edges  of  the  two 
lungs  approach  each  other  very  closely. 

The  summit  of  the  dome  of  the  liver  in  front  reaches 
as  far  as  the  4th  interspace  on  the  right  side,  but  it 
is  covered  with  a  ^^  edge-shaped  extension  of  the  lungs  as 
far  as  the  6th  rib,  where  what  is  known  as  the  absolute 
dulness  of  the  liver  begins,  the  lesser  impairment  of 
resonance  appearing  at  about  the  5th  rib  being  called 
relative  dulness. 

It  is  to  be  remembered  that  in  quiet  breathing,  during 
which  the  boundaries  above  traced  are  supposed  to  be 
maintained,  the  anterior  edge  of  the  left  lung  and  the 
inferior  edges  of  both  lungs  do  not  reach  the  extreme 
limit  of  the  pleural  space,  so  that  between  the  edges  of 
the  lungs  aird  the.  limit  of  the  pleural  sac  there  remains  a 
space  which  is  only  filled  at  the  time  of  deep  inspiration. 
At  o:her  times  the  costal  and  diaphragmatic  pleurae 
below  the  lower  edge  of  both  lungs  are  in  contact,  as 
are  also  the  costal  and  pericardial  pleurae  toward  the 
niedian  line  at  the  anterior  order  of  the  left  lung.  The 
spaces  thus  formed  ate  called  complemental  spaces. 

Above   the   level   of   the   4th   cartilages   the   anterior 


MEDICAL  ANATOMY  OF  THE  THORAX.         25 

edges  of  the  lungs  closely  approximate  and  fill  the 
pleural  space,  but  below  this  the  edge  of  the  left  lung 
deviates  from  the  pleural  border  to  form  the  tongue- 
shaped  cardiac  indentation  referred  to.  The  inferior 
border  of  the  left  lung  extends  a  little  lower  than  that 
of  the  right,  more  particularly  between  the  parasternal 
and  the  mammillary  line,  where  it  extends  half  an  inch 
lower. 

It  is  less  important  to  know  the  interlobular  boun- 
daries of  the  lung.  The  two  principal  fissures  begin 
posteriorly  nearly  on  a  line  with  the  spines  of  the  scap- 
ulas. The  left  incisure  starts  under  the  dorsal  end  of 
the  4th  rib,  passes  downward  and  outward,  intersect- 
ing the  5th  rib  in  the  mid-axillary  line  terminating  at 
the  lower  edge  of  the  lung  at  its  junction  with  the  right 
parasternal  line  and  the  6th  rib.  The  right  incisure 
divides  at  about  two  or  2j^  inches  above  the  angle  of 
the  scapula  into  two  branches,  an  upper  and  a  lower, 
which  separate  the  upper  lobe  from  the  middle,  and  the 
middle  from  the  lower  lobe  of  the  lung.  The  upper 
branch  passes  nearly  transversely  forward  to  terminate 
in  the  edges  of  the  lung  at  about  the  level  of  the  4th 
cartilage.  The  inferior  branch  passes  sharply  down- 
ward and  slightly  forward  at  the'  level  of  the  6th  rib  in 
the  neighborhood  of  the  mammillary  line,  and  out  at 
the  lower  edge  of  the  lung.  Hence  it  is  that  on  the 
posterior  aspect  the  Idwer  lobe  on  each  side  makes  tip  the 
larger  part  of  the  lungs  exposed  to  percussion  ;  on  the  left, 
in  front,  only  the  upper  lobe,  on  the  right  the  upper  and 
middle  lobes.     Laterally,  on  the  left  side  the  upper  and 


26  PHYSICAL    DIAGNOSIS. 

lower  lobe,  and  on  the  right  side  the  upper,  middle,  and 
lower  lobes  approach  the  surface. 

The  bifurcation  of  the  trachea  corresponds 
anteriorly  with  the  lower  end  of  the  manubrium,  pos- 
teriorly with  the  cartilaginous  disc  between  the  4th 
and  5  th  dorsal  vertebrae. 


INSPECTION  AND  MENSURATION. 

The  appearances  of  the  regions  described,  during  and 
independent  of  the  motions  of  breathing,  are  objects  of 
inspection  but  these  are  best  described  in  connection 
with  the  conditions  which  modify  them.  In  inspecting 
the  chest  from  the  front  or  behind,  the  patient  should 
stand  erect  with  the  hands  at  his  side ;  during  lateral 
inspection  the  hands  should  be  raised  alongside  of  the 
head,  or  they  may  grasp  opposite  shoulders.  Such  rela- 
tions to  light  should  be  chosen  as  will  obviate  shadows 
as  much  as  possible.  It  will  be  remembered  that  during 
breathing  a  woman  exhibits  more  motion  in  the  upper 
part  of  the  chest,  while  in  men  abdominal  motion  is 
marked. 

Mensuration  is  for  the  most  part  practised  by  an 
ordinary  tape  measure,  and  thus  the  circumference  of 
the  chest  at  different  situations  is  determined  ;  aiso  dif- 
ferences in  the  circumference  at  the  end  of  inspiration 
and  of  expiration,  and  differences  in  the  semi-circum- 
ference as  the  result  of  abnormal  states.  It  is  to  be 
borne  in  mind  that  in  right-handed  persons  the  semi- 
circumference   of   the   right   side    is   often    ^    inch   to 


THE  SHAPES  OF  THE  CHEST.  27 

one  inch  greater  than  that  of  the  left,  owing  to  the 
greater  muscular  development  of  that  side.  The  reverse 
obtains  to  a  less  degree  in  left-handed  individuals.  The 
transverse  and  antero-posteiior  diameters  of  the  chest 
may  be  determined  by  a  pair  of  calipers  ;  any  deviations 
in  the  shape  of  the  chest  by  the  cyrtometer,  a  simple 
form  of  which  may  be  made  out  of  strips  of  sheet  lead, 
moulded  to  the  chest-walls,  and  the  outline  thus  pro- 
duced is  drawn  on  a  large  sheet  of  paper.  More  perfect 
appliances  for  chest  measurement  are  the  stethometer  of 
Quain,  the  stetho-goniometer  of  Allison,  the  cyrtometer 
of  Woillez,  and  others,  but  they  are  not  needed  for  the 
usual  measurements. 


THE  SHAPES  OF  THE  CHEST. 

By  inspection  and  mensuration  we  learn  the  shape  of 
the  chest. 

I.  The  normal  shape  of  the  infant's  chest  at  birth 
is  nearly  cylindrical,  but  as  development  proceeds  it 
asquires  an  oval  shape  well  established  by  the  time 
the  child  has  cut  its  milk  teeth.  This  increases  slowly 
until  development  is  complete,  when  the  outline  shown 
in  Fig.  5  is  attained. 

During  maturity  the  chest  retains  this  shape,  but  with 
the  wane  of  life  and  the  effect  of  disease  incident  to  it 
there  come  changes  which  cause  the  chest  again  to  ap- 
proach the  cylindrical  shape  of  infancy. 

The  effect  of  various  diseases  on  the  shape  of  the 
chest  will  be  considered  in  connection  with  the  diseases 


28 


PHYSICAL    DIAGNOSIS. 


themselves,  but  there  are  several  types  presented  by 
those  in  apparent  health  which  are  important,  in  that 
they  favor  tendencies  to  special  diseases  or  are  the  result 
of  weakness  in  childhood 

2.  Thus  we  have  the  alar  or  pterygoid  chest,  which 
is  one  of  the  forms  of  the  so-called  phthisical  chest,  be- 
cause supposed  to  favor  the  development  of  this  disease. 


Fig.   5. — Tr.\ksverse  Section  of  Healthy  Adult  Chest   at    Level  of 
Sterno-xiphoid  Articulation. —  {After  Gee.) 


Such  a  chest  is  small;  the  angles  of  the  scapulae  project 
so  as  to  give  the  appearance  of  wings.  It  is  narrow, 
shallow,  and  long ;  but  the  ratio  between  the  antero- 
posterior and  transverse  diameters  is  not  necessarily 
changed.  The  ribs  droop  or  are  unduly  oblique.  The 
throat  is  prominent,  the  neck  long  and  the  head  bent 
forward. 


THE    SHAPES    OF    THE    CHEST.  29 

3.  Then  there  is  the  flat  chest,  also  phthisical, 
wherein  the  antero-posterior  diameter  is  dispioportion- 
ately  short,  owing  to  the  loss  of  convexity  in  the  carti- 
lages, which  are  even  sometimes  turned  in  so  that  the 
sternum  is  depressed  between  the  cartilages,  producing 
a  form  of  chest  which  on  section  is  kidney-shaped. 

In  this  form  of  chest  there  is  not  the  obliquity  of  the 
ribs  characteristic  of  the  alar  chest.  Both  the  flat  and 
alar  chests  are  known  2js,  phthinoid  c\\fs,i%. 

4.  The  transversely  constricted  chest  is  charac- 


FiG.  6. — Pigeon  Breast,  Child  of  Seven  Years. 
(Dotted  line  indicates  natural  shape  at  same  age. —  {After  Gee.) 

.terized  by  a  depression  of  varying  depth  known  as 
Harrison's  sulcus.  It  passes  outward  and  slightly 
downward  on  a  level  with  the  xiphoid  cartilage  and  as 
far  as  the  mid  axillary  line.  It  is  produced  in  child- 
hood by  some  obstruction  to  the  entrance  of  air,  usually 
a  bronchial  catarrh,  as  the  result  of  which  the  upper 
part  of  the  chest  is  not  expanded,  while  the  lower  part 
is  held  upward  by  the  abdominal  viscera.  It  is  especially 
frequent  in  rickets. 


30 


PHYSICAL    DIAGNOSIS. 


5.  The  pigeon  breast  is  the  result  of  higher  degrees 
of  obstruction  than  are  produced  by  simple  catarrhal 
conditions.  Whooping-cough,  with  its  prolonged  par- 
oxysms, is  probably  the  most  frequent  cause,  but  any 
chronic  pulmonary  catarrh  may  do  it,  as  may  also  en- 
larged tonsils.  In  it  the  shape  of  the  transverse  section 
of  the  chest  is  more  or  less  triangular,  the  result  of  a 
straightening  of  the  ribs  and  forward  protrusion  of  the 


Fig.  7. — Rickety  Chest. 

Dotted  line  indicates  the  shape  of  the  chest  of  an  infant  about  the  same 
age. —  {After  Gee.') 


sternum,  which  takes  place  while  the  ribs  are  plastic  and 
yielding.  The  pigeon  breast  is  usually  associated  with 
the  transverse  constriction  above  described,  both  being 
the  result  of  different  degrees  of  the  same  cause. 

6.  The  rickety  chest  is  characterized  by  a  shallow 
longitudinal  groove  on  each  side  of  the  chest,  parallel 
and  a  little  external  to  the  sternum.  It  is  due  to  exter- 
nal atmospheric  pressure  upon  soft,  rickety  ribs  before 
the  lungs  are  sufficiently  filled  to  occupy  the  space  ren- 


THE  SHAPES  OF  THE  CHEST.  3 1 

dered  vacant  by  the  descent  of  the  diaphragm.  The 
groove  takes  the  position  it  does  because  the  softest 
parts  of  the  ribs  are  about  the  costo-chondral  articula- 
tions. 

In  addition  to  the  shapes  of  chest  described,  inspec- 
tion recognizes  local  bulgings,  and'  shrinking  or 
depression,  deficient  expansion,  the  breathing 
rate,  and  change  of  rhythm. 

Litten's  Sign  —The  Diaphragm  Phenomenon. 
— Inspection  also  recognizes  Litten's  sign,  a  wave-like 
retraction  during  inspiration  of  the  intercostal  spaces  on 
the  frontal,  lateral,  and  dorsal  aspects  of  the  thorax.  It 
is  ascribed  to  the  peeling  off  of  the  diaphragm  fiom  its 
thoracic  contact,  coincident  with  the  descent  of  the 
lun-gs,  in  the  act  of  inspiration. 

It  is  seemingly  the  direct  result  of  external  atmos- 
pheric pressure  anticipating  the  balance  of  pressure  sub- 
sequently restored  by  the  complete  expansion  of  the 
lung.  It  is  said  to  occur  in  all  healthy  individuals, 
but  is  plainer  in  those  who  are  thin.  Its  lower  limit 
in  health  corresponds  with  the  lower  boider  of  the  lung. 
It  is  said  to  be  absent  in  laige  pleural  effusions  and 
emphysema  of  the  lung,  diminished  in  small  effusions. 
The  effect  of  the  latter  is  to  lower  the  line  at  which 
it  begins,  which  is  usually  the  6th  interspace. 


$2  ?H\'SICAL    DLA.GNOSIS. 

PALPATION. 

After  inspectioD  axid  mensuration  of  the  chest,  palpa- 
tion is  usually  practised.  This  is  done  by  applying  the 
palm  of  the  hand  or  the  fingers,  as  may  best  serve  the 
purpose,  to  the  chest-wall.  The  chief  value  of  palpa- 
tion lies  in  the  fact  that  when  the  hand  is  thus  closely 
applied,  and  the  person  "  touched  "  speaks,  a  peculiar 
vibrating  or  trembling  sensation  is  conveyed  to  the 
hand.  This  is  known  as  vocal  fremitus  or  tactile 
fremitus.  This  fremitus  or  thrill,  representing  the 
vibiations  communicated  to  the  air  by  the  vocal  cords, 
is  conveyed  to  the  walls  of  the  air  passages,  from  the 
larger  to  the  smaller,  until  the  ultimate  structure  of  the 
lung  is  reached,  whence  it  is  conveyed  to  the  chest-wall 
and  hands.  In  health  it  is  felt  everywhere  over  the 
chest  where  lung-tissue  reaches,  but  is  more  distinct 
where  the  chest-walls  are  thinnest,  and  especially  in  the 
infraclavicular  spaces.  It  is  further  often  more  plainly 
felt  below  the  right  clavicle  than  below  the  left,  an  im- 
portant fact  to  be  remembered  in  recognizing  delicate 
shades  of  difiference.  This  is  usually  explained  by  the 
fact  that  the  right  bronchus  is  shorter,  larger,  and  enters 
the  lung  higher  up  and  more  horizontally  than  the  left, 
whence  a  larger  volume  of  air  is  contained  in  the  right 
lung,  especially  in  its  upper  jwrtion,  and  stronger  vibra- 
tions are  produced  in  speaking.  For  the  same  reason 
vocal  fremitus  is  sometimes  slightly  more  distinct  pos- 
teriorly in  the  right  half  of  the  interscapular  space  and 
even  below  the  angle  of  the  right  scapula.  In  the  axilla 
the  same  difference  may  exist  to  a  less  degree.     Tactile 


PALPATION.  33 

fremitus  is,  of  course,  more  marked  in  persons  with  thin 
chest-walls  than  in  those  with  thick  muscular  walls,  or 
walls  covered  with  fat,  while  it  is  feebler  but  still  easily 
appreciable  in  women.  It  is  also  greatly  influenced  by 
the  pitch  or  tone  of  the  voice  used,  being  more  marked 
in  a  deep,  low-toned  speech  than  in  a  high  one.  It  is 
further  influenced  by  words  selected  for  utterance.  My 
favorites  are  "  ninety  nine,"  as  producing  a  longer 
vibration  than  words  hke  "  sixty-six,"  for  instance.  But 
"  one,  two,  three,"  or  "  twenty-one,"  '■'  twenty-tAvo," 
and  "  twenty-three,"  and  the  like,  are  useful  also  to 
bring  out  vocal  fremitus. 

Vocal  fremitus  is  increased  in  abnormal  states  pro- 
ducing consolidation  of  the  lung,  as  in  pneumonia  and 
tubercular  deposit,  and  is  diminished  by  conditions 
which  separate  the  lungs  from  the  chest-wall,  as  pleuritic 
effusions,  plastic  pleuritic  thickening,  and  even  solid 
tumors. 

Fremitus  is  also  produced  by  the  action  of  coughing, 
when  it  is  called  tussile,  as  distinguished  from  vocal; 
by  rales,  dry  or  moist,  if  the  tubes  are  of  sufficient  calibre, 
when  it  is  called  rhonchal ;  also  by  pleural  and  peri- 
cardial friction. 

By  palpation  is  also  recognized  the  resistance  due 
to  increased  density  of  an  organ. 

Palpation  co  operates  with  inspection  in  recognizing 
the  relative  excursion  of  breathing  movement  on 
the  two  sides  of  the  chest,  shght  degrees  of  difference 
in  which  being  often  difficult  to  discover. 

Cardiac  and  vascular  thrills  are  also  felt  in  dis- 
eases of  the  heart  and  blood-vessels. 


34 


PHYSICAL    DL4GNOSIS. 


PERCUSSION. 

Percussion  naturally  succeeds  palpation,  and  consists 
in  striking  a  part  with  a  view  to  eliciting  sound.  In  its 
simplest  form  it  is  probably  as  old  as  diagnosis  itself, 
but  Leopold  Auenbrugger,  of  Vienna,  was  the  first  to 
publish,  in  1761,  results  obtained  from  its  application. 
Percussion  is  called  immediate  or  mediate,  accord- 


FiG.  8. — Percussion  Hammer  or  Plexor. 


Fig.  9. — Ivory  Pleximeter.    Fig.  io. — Sansom's  Pleximeter. 


ing  as  the  blow  is  struck  directly  upon  the  part  or  upon 
some  interposed  medium.  Immediate  percussion  is  of 
limited  application,  but  it  is  still  sometimes  very  useful, 
and  I  much  like  to  percuss  the  clavicular  region  by 
striking  directly  the  bone  rather  than  upon  some  inter- 
posed substance.  The  hammer  or  agent  by  which  the 
stroke  is  practised  is  the  plexor,   and  the  interposed 


PERCUSSION.  35 

material  is  the  pleximeter.  By  far  the  most  common 
plexor,  and  usually  the  best,  is  the  middle  or  index 
finger,  or  both  of  these,  while  one  or  the  other  of  the 
same  fingers  of  the  other  hand  becomes  tbe  pleximeter. 
It  is  often  useful,  however,  to  have  a  specialized  ham- 
mer, like  that  shown  in  Fig.  8,  while  more  useful  and 
even  more  indispensable  at  times  becomes  a  pleximeter 
(Figs.  9  and  lo),  in  situations  which  the  fingers  cannot 
conveniently  reach,  or  where  there  is  much  percussing  to 
do,  when  the  fingers  sometimes  become  sore  and  tender 
from  the  constant  pounding.  By  far  the  most  satisfac- 
tory pleximeter,  in  my  experience,  is  the  little  hard- 
rubber  pleximeter  suggested  by  Sansom.  (See  Fig.  lo.) 
Either  the  larger  or  smaller  end  may  be  applied  to  the 
chest,  and  the  stroke  given  to  the  other,  with  equal 
efiiciency. 

The  pleximeter  was  invented  and  first  used  by  Piorry, 
of  Paris,  in  1828,  and  the  hammer  by  Wintrich,  in 
1841. 

The  essential  conditions  of  successful  per- 
cussion are,  first,  the  close  application  of  the  plexi- 
meter, whether  it  be  the  finger  or  an  artificial  pleximeter, 
to  the  chest,  so  that  it  will  form  a  part,  as  it  were,  of 
the  area  to  be  percussed  ;  and,  as  the  two  sides  of  the 
thorax  are  commonly  compared,  precisely  correspond- 
ing points  should  be  selected.  Then  care  should  be 
taken  to  strike  with  equal  force  on  each  side.  When 
the  fingers  are  used  as  plexors,  the  stroke  should  be 
made  from  the  wrist,  and  vertically  on  the  pleximeter, 
while    the    hand    should    be    raised    quickly,    and    one, 


30  PHYSICAL    DIAGNOSIS. 

two,  three,  or  more  blows  given  until  the  proper  sound 
of  the  part  is  elicited.  To  this  end  the  force  of  the 
stroke  should  be  regulated,  being  made  lighter  on  thin- 
walled  chests  and  more  forcible  over  thicker  walls. 
When  the  proper  note  is  brought  out  it  should  be  re- 
membered and  compared  with  the  sound  elicited  under 
the  same  conditions  at  the  corresponding  point  on  the 
opposite  side.  Practice  with  attention  to  these  condi- 
tions can  alone  make  perfect. 

The  sound  produced  by  percussing  the  chest  is  a 
mixed  one,  made  up  of  the  vibrations  of  the  pleximeter, 
those  of  the  thoracic  wall,  and  those  of  the  air  in  the 
lungs.  The  first,  when  the  finger  is  used  as  a  pleximeter, 
is  scare elv  noticeable,  but  when  a  pleximeter  of  ivory 
or  hard  rubber  is  used  this  element  may  be  recognized, 
especially  when  the  pleximeter  is  accidentally  struck  by 
the  nail  of  the  finger  used  as  a  plexor.  In  like  manner 
the  vibrations  of  the  thoracic  wall  are  insignificant  and 
unnoticeable  under  ordinal}'  circumstances,  in  com- 
parison with  the  vibrations  of  the  air  in  the  lungs,  which 
are  responsible  for  most  of  the  sound  produced  in  per- 
cussing the  normal  chest.  These  vibrations  are  set  up 
by  the  blow,  and  it  is  the  sound  thus  produced,  variously 
modified  in  health  and  disease,  which  we  are  to  study. 
Where  the  chest-wall  is  very  thick,  however,  the  note  of 
its  percussion  becomes  more  predominant  and  that  of 
the  lungs  less. 

Auscultatory  or  stethoscopic  percussion  is  a 
term  applied  to  a  method  introduced  by  Cammann  and 
Clark,   which   consists   in   listening,  A^ith   a   stethoscope 


PERCUSSION. 


37 


applied  to  the  chest-  walls, 
to  the  sounds  obtained  by 
percussion.  Such  sounds  are 
much  intensified  when  thus 
conveyed  to  the  ear.  The 
boundaries  of  organs  may, 
therefore,  be  thus  marked 
out  with  greater  precision 
because  of  the  more  sudden 
change  of  note  when  they 
are  passed.  So  long  as  both 
plexor  and  stethoscope  are 
placed  over  the  same  organ 
the  intensity  continues,  but 
as  soon  as  either  passes  the 
limits  of  the  organ  the  per- 
cussion note  becomes  feeble 
and  diffused.  This  form  of 
percussion  is  scarcely  enough 
appreciated,  as  information 
obtained  ])y  percussion  is 
rendered  more  precise,  while 
boundaries  may  be  thus  rec- 
ognized which  are  not  ob- 
vious to  ordinary  percussion, 
as  that  between  the  lower 
border  of  the  heart  and  the 
liver,  and  that  between  lobes 
of  the  lungs.  It  is  not  neces- 
sary to  tap  with  the  plexor, — 


Fig.  II.  —  The  Phonendoscope. 
Designed  by  Drs.  Eazzi  and 
Bmnchi. 


38  PHYSICAL    DIAGNOSIS. 

scraping  or  scratching  by  the  finger  or  a  pencil  may  be 
substituted. 

The  phonendoscope  is  an  instrument  by  which 
auscultatory  percussion  as  well  as  auscultation  is  ren- 
dered more  delicate.  It  consists  of  a  drum  or  cylinder 
(B),  one  surface  of  which,  covered  with  a  thin  sheet  of 
hard  rubber,  is  applied  to  the  part  to  be  examined, 
while  to  the  other  side  are  attached  rubber  tubes  and 
ear  pieces.  Small  areas  are  reached  by  means  of  a 
second  disc  of  hard  rubber,  into  which  is  screwed  a 
metal  cylinder  (A).  The  instrument  thus  arranged  is 
less  delicate  but  is  necessary  over  small  areas.  Scraping 
with  the  finger  is  practised,  and  the  same  intensity  of 
sound  described  under  stethoscopic  percussion  is  heard 
until  the  border  of  the  organ  is  passed,  when  the  sound 
suddenly  ceases. 

The  instrument  is  also  used  in  securing  greater  delicacy 
in  ausculting  breath-sounds  and  cardiac  murmurs;  but 
the  advantage  gained  by  its  use  is  scarcely  sufficient  to 
permit  it  to  replace  the  ordinary  stethoscope. 

Respiratory  percussion  is  a  term  proposed  by 
J.  M.  Da  Costa  for  the  study  of  a  note  made  by  per- 
cussion of  the  lungs  while  the  breath  of  the  patient  is 
held  after  a  deep  inspiration  or  after  a  prolonged  expira- 
tion. Constant  reference  will  be  made  to  the  effect  of 
the  latter  on  sounds  elicited  by  percussing  normal 
organs.  The  general  effect  of  a  full  breath  on  percus- 
sion is  to  increase  the  lung  resonance,  make  the  sound 
fuller  and  raise  the  pitch.  The  effect  is  more  marked 
on  the  right  side.  The  eft'ect  of  a  complete  expiration 
is  the  opposite. 


AITRIBUTES    OF    PERCUSSION    SOUNDS.  39 

ATTRIBUTES  OF   PERCUSSION   SOUNDS. 

Percussion  sounds  have  attiibutes  of  quality,  in- 
tensity or  loudness,  pitch,  and  duration.  No  one 
of  these  attributes  can,  strictly  speaking,  be  so  described 
as  to  enable  it  to  be  recognized  by  the  ear.  Practice 
and  illustration  must  be  associated  with  the  description 
in  order  that  an  adequate  idea  may  be  obtained. 

Quality  is  the  easiest  indicated  of  the  attributes  of 
sound.  Although  the  late  Dr.  Austin  Flint  truly  said 
that  "  to  attempt  to  describe  the  quality  of  sounds  to 
one  who  has  never  heard  them  would  be  like  describing 
colors  to  one  who  is  blind,"  illustration  happily  comes 
to  OUT  assistance  and  helps  greatly.  Thus  it  is  not  dif- 
ficult for  any  one  who  has  heard  it  to  recognize  the  note 
of  a  tuning-fork,  violin,  or  piano,  and  to  name  the  in- 
strument producing  it.  The  attribute  of  sound  by 
which  such  recognition  is  made  is  quality,  and  each 
quality  is  produced  by  certain  conditions  peculiar  to 
the  instrument  producing  the  sound.  It  varies  there- 
fore with  those  conditions. 

Now,  the  qualities  of  sound  produced  by  percussing 
the  normal  lung  are  mainly  two  :  First,  the  normal  7)es- 
iciilar  resonance  or  clear  sound ;  second,  the  dull  sound  or 
dulness.  There  are  modifications  of  both  of  these.  A 
third  quality,  not  strictly  speaking  a  normal  thoracic 
sound,  but  so  conspicuous  in  adjacent  organs  in  health 
as  often  to  influence  the  thoracic  sounds,  will  also  be  de- 
scribed in  this  connection.  I  allude  to  tympany.  Each 
of  these  is  produced  by  conditions  peculiar  to  itself. 


40  PHYSICAL   DIAGNOSIS 

Vesicular  resonance,  or  lung-clearness,  as  applied 
to  the  healthy  chest,  is  produced  by  percussion  over 
normal  air-distended  lung  tissue,  a  structure  containing 
air  in  minutely  divided  spaces.  Such  structure  is  its 
condition,  and  the  sound  produced  is  as  much  siii  generis 
as  is  the  violin's  sound.  It  is  of  the  nature  of  a  rever- 
beration, and  is  reverberation  modified  by  minute 
subdivision  of  air  spaces.  It  was  compared  by  Auen- 
brugger  to  the  sound  of  a  drum  covered  with  a  thick 
woolen  fabric,  and  not  inaptly  by  Flint  to  the  sound 
produced  by  percussing  a  loaf  of  bread  over  which  a 
towel  has  been  spread,  the  upper  crust  of  the  bread 
corresponding  to  the  chest-wall ;  but  it  does  not  do  to 
take  this  illustration  too  literally.  Normal  lung  reso- 
nance differs  in  different  parts  of  the  chest  of  the  same 
individual  and  in  different  individuals.  Its  typical 
quality  may  always  be  found  in  the  left  infraclavicular 
space  or  below  the  angle  of  eithei  scapula  in  healthy 
persons  with  chest-walls  of  moderate  thickness. 

The  chief  cause  which  operates  to  produce  the  differ 
ences  alluded  to  in  health  is  the  varying  thickness  of  the 
chest- walls  and  the  intervention  of  bone,  as  a  rib,  the 
clavicle,  or  sternum.  But  the  state  of  tension  of  the  air 
in  the  air  vesicles  has  to  do  with  it,  as  has  also  the 
position  of  adjacent  viscera  and  the  mode  of  percussion, 
according  as  it  is  forcibly  or  lightly  practised,  according 
as  it  is  well  or  faultily  done.  The  differences  themselves 
consist  in  variations  in  the  other  three  attributes  named 
— intensit5f,^3itch,  and  duration. 

Intensity  means  simply  loudness  and  increases /an 


ATTRIBUTES    OF    PERCUSSION    SOUNDS.  4 1 

passu  with  the  thinness  of  the  chest-wali  and  the  force 
of  the  percussion  blow.  The  effects  of  the  attributes  of 
pitch  and  duration  are  best  studied  after  the  other 
quah'ties  mentioned,  dulness  and  tympany,  are  con- 
sidered. 

Dulness  in  general  may  be  defined  as  diminished 
resonance,  but  the  term  is  not  used  by  all  authors  with 
a  single  meaning.  I  do  not  think  Da  Costa's  description 
can  be  improved  upon.  He  says,*  "  a  dull  sound 
denotes  the  absence  of  air.  It  is  the  sound  both  of 
fluids  and  solids.  It  is,  thus,  the  sound  sent  forth  by 
the  airless  viscera;  from  the  liver,  spleen,  and  heart." 
The  term  flatness  is  essentially  synonymous,  although 
also  used  to  indicate  a  higher  degree  of  dulness.  To 
retain  the  word  flatness  for  the  sound  produced  by  per- 
cussing an  absolutely  airless  organ  or  fluid,  and  dulness 
for  resonance  diminished  in  positive  degree,  gives  a 
desirable  latitude  in  the  use  of  terms,  further  increased 
by  the  application  of  the  adjective  terms  slight,  moder- 
ate, considerable,  or  marked.  I  shall  therefore  use  the 
term  in  this  sense.  Dulness  and  flatness  are  both 
associated  with  increased,  resistance  to  the  percussing 
finger,  a  sign  also  more  or  less  valuable  in  diagnosis. 

Tympany  or  tympanitic  resonance  is  the  sound 
elicited  by  percussing  over  a  large  cavity  filled  with  air 
— a  cavity  whose  walls  are  rather  thin,  and  neither  very 
tense  nor  very  yielding.  The  stomach  and  intestines 
furnish  such  a  cavity,  and  it  is  in   this  region   that  we 


*  "  Medical  Diagnosis,"  7th  ed.,  1890,  p.  264. 


42  PHYSICAL    DIAGNOSIS. 

seek  the  tympanitic  quality  of  resonance.  Tympany 
also  has  variations  in  pitch  due  to  variations  in  the  size 
of  cavities,  which  will  be  better  understood  after  this 
attribute  of  sound  is  considered. 

Pitch  and  Duration  — We  are  now  ready  to  discuss 
and  illustrate  the  attributes  of  pitch  and  duration, 
neither  of  which  are  so  easily  described  as  quality  and 
intensity.  They  can,  indeed,  only  be  learned  by  prac- 
tice and  with  varying  facility  by  different  ears,  the 
musical  ear  having  a  decided  advantage.  Perseverance, 
however,  will  enable  any  one  to  appreciate  them  suffi- 
ciently for  practical  purposes. 

First  as  to  pitch.  VVe  speak  of  it  as  high  or  low  and 
of  intermediate  degre.e  Pitch  is  higher  the  more  rapid 
is  the  succession  of  the  vibrations  of  the  sounding  body 
and  of  the  sound  waves  which  emanate  from  it,  while 
intensity  depends  on  the  amplitude  of  the  vibrations.* 
Shrillness  is  the  acme  of  pitch,  loudness  of  intensity. 
The  higher  the  tension  of  a  percussed  cavity  containiilg 
air  the  more  numerous  the  vibrations  and  the  higher  the 
pitch,  but  the  shorter  the  amplitude  of  the  vibrations 
and  therefore  the  less  the  intensity.  Vice  versa,  a 
high-pitched  tympanitic  resonance  would  indicate  a 
smaller  cavity  with  tenser  walls  than  low-pitched  tym- 
pany.    The  normal  vesicular  resonance  is  characterized 


*  Amplitude  is  the  length  of  the  excursion  of  the  particles  which 
at  any  time  form  the  sonorous  wave,  and  the  motion  of  the  particles 
or  their  width  of  swing  must  not  be  confounded  with  the  motion  of 
the  sonorous  wave  itself. 


ATTRIBUTES   OF   PERCUSSION   SOUNDS.  43 

oy  its  low  pitch,  because  the  air  vesicles  are  not  in  a 
state  of  high  tension.  If,  however,  the  lungs  be  forcibly 
dilated,  the  air  vesicles  are  placed  in  a  state  of  higher 
tension  and  of  diminished  elasticity,  a  situation  akin 
to  that  of  a  distended  stomach,  and  if  percussion  be 
now  practised  over  such  areas  the  pitch  will  be  raised, 
but  there  will  be  added  not  only  a  higher  pitch,  but 
also  a  tympanitic  quality,  and  a  note  will  be  produced 
which  was  named  by  Dr.  Flint  vesiculo-tympanitic 
resonance.  It  is  a  mixed  note,  therefore,  and  its 
conditions  are  produced  by  any  cause  which  over-dis- 
tends the  air  vesicles,  as  prolonged  crying  in  a  child. 
It  is  also  the  note  of  the  over-distended  air  vesicles  in 
emphysema  of  the  lung  or  of  portions  of  a  lung,  sup- 
plementally active  in  consequence  of  impairment  of 
function  in  other  parts. 

Tympanitic  sounds,  although  generally  high-pitched, 
also  vary  in  pitch,  the  latter  increasing  inversely  as  the 
size  of  the  cavity  and  directly  with  the  degree  of  ten- 
sion. Thus  the  stomach,  being  a  large  cavity,  gives  to 
percussion  a  lower  pitch  than  the  small  intestine  dis- 
tended to  an  equal  degree.  On  the  other  hand,  tension 
may  be  made  so  great  by  forcible  distension,  say  of  the 
stomach,  that  the  tympanitic  sound  may  be  destroyed. 

When  a  bladder  or  stomach  is  so  forcibly  distended 
that  its  percussion  produces  a  dull  sound  instead  of  a 
tympanitic  one, — and  such  distension  is  only  possi- 
ble when  the  air  space  is  tightly  closed  on  all  sides, — it 
is  as  though  the  air  space  were  surrounded  by  unyield- 
ing walls.     Percussion    under    these    circumstances — a 


44  PHYSICAL    DIAGNOSIS. 

thoroughly  closed  cavity  and  firm  walls — produces  no 
t3'mpany.  The  observer  hears,  for  the  most  part,  only 
the  sound  produced  by  the  vibrations  of  the  bladder 
wall,  influenced  in  part  by  the  convex  shape  of  the 
bladder,  and  in  part  by  the  condensed  air  witnin  it. 
The  pressure  of  this  air  resists  the  inward  vibration  of 
the  bladder  wall,  and  by  shortening  the  amplitude  of  the 
air  vibrations  diminishes  the  intensity  and  resonance  of 
the  sound.  In  a  word,  it  is  shorter,  duller,  non-tym- 
panitic.  If,  however,  the  mass  of  air  thus  surrounded 
by  a  tense  wall  communicates  with  the  exteiior  by  an 
opening,  the  tympanitic  note  responds  to  percussion. 

Dull  and  flat  percussion  are  high  pitched  in  their 
note,  and  the  pitch  increases  with  the  dulness  and  the 
area  of  the  dulness,  while  the  first  suggestion  of  im- 
paired resonance  is  a  slight  heightening  of  pitch  which 
the  practised  ear  readily  recognizes,  and  attaches  to  it 
great  importance.  The  suggestion  of  a  higher  pitched 
note  just  below  the  right  clavicle  in  health  as  compared 
with  the  note  of  the  corresponding  region  on  the  left, 
is  also  to  be  remembered  in  weighing  slight  differences 
in  the  percussion  note  of  the  two  sides.  It  is  associated 
with  the  tendency  to  increased  vocal  fremitus  in  the 
same  situation,  already  referred  to. 

The  explanations  of  this  tendency  to  a  slightly  higher 
pitched  note  and  slight  dulness  at  the  right  apex  are 
not  uniform,  and  best  considered  in  a  footnote.* 


*  One  explanation  of  this  slight  impairment  of  the  resonance  is 
based  on  the   different  arrangement  of   the  bronchial  tubes  on  the 


PERCUSSION    OF    THE    NORMAL    CHEST.     '  45 

Duration  is  the  attribute  of  least  importance,  or  at 
least  comes  little  into  play  in  the  percussion  of  the 
human  body.  It  varies  inversely  with  the  pitch,  that 
is,  the  higher  the  pitch  the  shorter  the  duration,  and 
vice  versa. 

We  are  now  ready  to  study  the  percussion  sounds  as 
heard  in  the  different  regions  of  the  chest  as  already 
mapped  out. 

PERCUSSION    OF   THE    NORMAL    CHEST— TOPO- 
GRAPHICAL PERCUSSION. 

First,  in  the  supraclavicular  spaces. 
Satisfactory  percussion  here  is  difficult  and  results  are 

right  side  as  compared  with  the  left.  The  former  are  larger,  extend 
higher  up  than  the  latter,  and  thus  give  more  tubular  tissue,  in- 
cluding a  larger  proportion  of  connective  and  muscular  tissue  to 
deal  with  in  percussing,  which  would  cause  shghtly  less  resonance. 

A  second  explanation,  which  certainly  must  be  allowed  to  apply 
in  some  instances,  is  the  greater  muscular  development  of  the  right 
side  of  the  body,  and  in  consequence  greater  thickness  of  the  pec- 
toral muscles  of  that  side.  This  would  also  cause  a  slightly  higher 
pitch.  The  opposite  state  of  affairs  in  left-handed  persons  would  go 
far  to  confirm  this,  but  I  am  not  aware  of  any  systematic  observa- 
tions intended  to  settle  this  question. 

Still  another  explanation  of  this  difference  is  based  on  the  fact 
that  the  right  lung  rests,  through  the  diaphragm,  upon  the  right  lobe 
of  the  liver,  which  is  a  dense  organ,  and  percussion  of  the  lung 
would  be  modified,  by  such  relation,  toward  a  slight  impairment  of 
resonance.  It  is  not  impossible  that  any  one  or  more  of  the  first 
three  causes  might  operate  to  produce  the  difference  on  the  two 
sides,  the  last  cause  more  particularly  in  explaining  any  slightly 
raised  pitch  in  the  lower  lobe  as  compared  with  the  left. 


46  PH\'5ICAL    DLA.GNOSIS. 

not  to  be  too  much  relied  upon.  The  nearest  approach 
to  normal  clear  percussion  or  vesicular  resonance  is 
found  above  the  centre  of  the  cla^^cles  where  the  lungs 
rise  from  Ji^  inch  to  1J2  or  even  two  inches  above  the 
clavicle,  being  usually  higher  in  women  than  in  men. 
Toward  the  inner  end  of  the  clavicle  the  percussion  may 
acquire  a  more  tjTiipanitic  quality,  on  account  of  the 
proximity  of  the  trachea,  while  toward  the  outer  end  a 
duller  note  obtains. 

On  the  clavicles  themselves  the  percussion  note  is 
clear,  almost  typically  so,  over  the  middle  of  the  bone, 
but  becomes  duller  as  the  outer  end  is  approached,  while 
on  the  inner  end  it  may  be  higher  pitched — osteal. 

The  infraclavicular  spaces  furnish  in  health  the 
t}'pical  clear  lung  note  or  vesicular  resonance  through- 
out these  spaces.  On  the  right  side  is  to  be  looked  for 
the  shadowy  higher  pitch,  less  clearness,  and  shorter 
duration,  so  that  the  left  subclavicular  may  be  selected 
as  affording  typically  normal  lung  resonance.  This  dif- 
ference is  not  invariable,  but  the  fact  is  to  be  remem- 
bered in  weighing  shades  of  difference  with  a  view  to 
diagnosis. 

In  the  mammary  region  percussing  down  the  right 
mammillar}-  hne,  the  clearness  continues,  possibly  a 
trifle  less  on  account  of  the  greater  thickness  of  the 
pectoral  muscle,  until  the  4th  interspace  or  the  5th  rib 
is  reached,  when  there  is  a  raised  pitch  and  diminished 
intensit}^,  which  passes  at  the  6th  rib  into  a  positive 
dulness  which  continues  in  health  to  the  edge  of  the 
ribs.     This  impairment  of  the  resonance  on   the  right 


PERCUSSION    OF    THE    NOR-MAL    CHEST.  47 

side  is  due  to  the  liver,  the  lesser  degree  being  known 
as  the  deep  or  relative  dulness,  and  below  this  the 
absolute  dulness.  The  upper  border  of  the  absolute 
dulness  corresponds  with  the  lower  edge  of  the  right 
lung.  Close  to  the  sternum  on  the  right  side  there  may 
be  slight  impairment  of  resonance  from  the  3d  to  the 
5th  rib,  due  to  the  relative  dulness  of  the  right  auricle, 
passing  at  the  5th  rib  into  the  relative  dulness  of  the 
liver,  and  at  the  6th  into  the  flatness  of  that  organ. 
On  forced  inspiration  the  liver  is  pushed  downward  an 
inch  or  more,  and  on  forced  expiration  there  is  a  cor- 
responding rise. 

On  the  left  side,  close  to  the  sternum,  normal  vesicular 
resonance  begins  to  lessen  at  the  3d  interspace,  owing 
to  the  deep  or  relative  dulness  of  the  heart,  and  at  the 
4th  costal  cartilage  is  replaced  by  the  absolute  dulness 
of  this  organ,  which  continues  down  along  the  left  edge 
of  the  sternum  until  it  passes  into  the  left  lobe  of  the 
liver,  from  which  it  cannot  be  demarked ;  but  in  gen- 
eral terms  the  absolute  cardiac  dulness  may  be  said  to 
extend  from  the  4th  to  the  6th  rib  along  the  left  edge 
of  the  sternum  ;  and  from  the  sternum  to  a  cur\-ed  line 
extending  a  short  distance  along  the  4th  cartilage  and 
thence  down  within  the  nipple  line  to  the  seat  of  the 
apex-  beat,  the  line  of  relative  dulness  being  a  short 
distance  outside  of  this.  (See  Fig.  12.)  The  cardiac 
area  of  dulness  is  also  diminished  on  deep  inspiration, 
because  the  organ  becomes  more  fully  covered  bv  the 
distended  lungs.  External  to  the  nipple  on  both  sides 
there   is,   in  health,    resonance  to  the  anterior  axillary 


48  PHYSICAL   DL4GN0SIS. 

line,  slightly  lessened  by  the  mamman'  gland  and  pec- 
toral muscle. 

The  inframammary  region  on  the  right  side  is 
wholly  occupied  by  the  liver  and  furnishes  flat  percus- 
sion, beginning  in  the  mammillary  line  at  the  6th  rib, 
rising  with  this  rib  as  the  sternum  is  approached.  In 
the  mammillary  line  it  extends  to  the  edge  of  the  thorax. 
The  extent  of  the  area  of  absolute  dulness  of  the  liver 
is  three  to  four  inches. 

On  the  left  side  the  percussion  in  the  inframammary 
region  varies  greatly  in  different  persons  and  in  the  same 
person  at  different  times.  Near  the  tip  of  the  sternum 
and  a  short  distance  below,  the  left  lobe  of  the  liver  for 
the  most  part  maintains  its  dulness,  but  even  this  is 
sometimes  replaced  by  the  tympany  of  a  gas-distended 
stomach,  while  to  the  outside  of  this  the  stomach  as 
normally  distended  with  gases  quite  frequently  imparts 
a  tympanitic  note.  On  the  other  hand,  the  presence  of 
solids  and  fluids  in  the  stomach  contributes  dulness 
in  various  degrees.  A  spleen  of  normal  size  does  not 
extend  into  the  inframammary  region.  In  this  connec- 
tion it  may  be  mentioned  that  the  lower  edge  of  the 
liver  generally  corresponds  to  a  line  drawn  from  the  left 
6th  rib  within  the  mammillar}'  line  obliquely  across  the 
epigastrium  to  the  junction  of  the  right  mammillary 
line  with  the  edge  of  the  thorax. 

In  the  suprasternal  notch,  also  difficult  to  per- 
cuss, tracheal  tympany  may  be  brought  out  by  vertical 
percussion  on  a  suitably  placed  pleximeter.  Over  the 
upper  sternum,  as  far  as  the  3d  rib,  the  percussion  is 


Fig.  12. — Showing  Absolute  and  Relative  Percussion  Dulness  of  Liver 

AND  Heart. 

I.  Relative  dulness  of  liver.     2.  Absolute  dulness.     3.  Relative  dulness  of  heart. 

4.  Absolute  dulness. 


5©  Pm.-SICAL   DL4GN0SIS. 

resonant,  with  a  slightly  tympanitic  note  communicated 
by  the  trachea.  Below  this  for  a  short  distance  there  is 
a  purer  lung  note,  though  perhaps  slightly  less  resonant 
than  typical  lung  structure  because  of  the  underlying 
heart.  At  the  4th  rib  the  heart,  though  still  covered  in 
by  the  lungs,  begins  to  deaden  the  note,  which  is  still 
fairly  clear  in  the  median  line  until  the  liver  is  reached 
opposite  the  6th  rib,  where  dulness  is  absolute  and 
extends  one-third  to  half-way  to  the  umbilicus,  although 
a  tympanitic  stomach  may  also  influence  the  note. 
Toward  the  left  edge  of  the  sternum  from  the  4th  rib 
down  there  is  decided  impairment  of  resonance  caused 
by  the  heart  immediately  under  it. 

In  the  axillary  spaces  on  both  sides  there  is  good 
pulmonary  resonance.  In  the  infra-axillary  region  of 
the  right  side,  the  relative  dulness  of  the  liver  is  noted 
at  the  8th  rib  in  the  mid-axillary  line  and  the  absolute 
dulness  at  the  9th.  On  the  left  side  there  is  also  clear- 
ness until  the  spleen  is  reached  in  the  mid-axillary  line 
at  the  9th  rib,  whence  it  extends  to  the  nth.  Laterally 
the  spleen  extends  upward  and  backward  between  these 
two  ribs  from  two  to  three  inches,  and  sometimes  it  is 
so  covered  in  as  to  escape  recognition  by  careful  percus- 
sion. The  left  infra-axillary  region  is  also  apt  to  be 
encroached  upon  by  the  tympany  of  the  stomach. 

Posteriorly,  percussion  is  best  practised  with  the 
patient  leaning  slightly  fonvard  and  folding  his  arms. 
The  upper  border  of  the  lungs  behind  is  on  a  level  with 
the  spinous  process  of  the  7  th  cervical  vertebra. 

In  the   supraspinous  fossa  the  percussion  reso- 


PERCUSSION    OF    THE    NORMAL    CHEST,  5  I 

nance  is  markedly  less  than  typical,  because  of  the  bone 
and  the  thick  muscles  overlying  it,  and  the  same  may 
be  said  of  the  infraspinous  region.  At  the  same  time 
percussion  here  is  important  because  differences  on  the 
two  sides  are  usually  easily  recognizable. 

In  the  interscapular  region  there  is  again  better 
resonance  than  over  the  scapulse  themselves,  but  still 
less  intense  than  below  the  angles  of  the  scapulae,  on 
account  of  the  tolerably  thick  muscles  and  the  spinal 
column.  In  the  upper  portion  the  tympany  of  the 
trachea  may  influence  the  note. 

In  the  infrascapular  regions  we  have  the  nearest 
approach  behind  to  the  typical  resonance  as  represented 
by  the  left  infraclavicular  space.  The  information  ob- 
tained here  by  percussion  is  most  valuable,  only  equaled 
in  importance  by  that  obtained  by  percussing  below  the 
clavicles,  and  in  consequence  of  this  it  is  important  to 
remember  the  inferior  border  of  the  normal  resonance. 
The  lower  border  of  the  lung  in  the  line  of  the  angle  of 
the  scapula  corresponds  on  both  sides  to  the  loth  rib, 
where,  on  the  right  side,  the  absolute  dulness  of  the 
liver  is  found,  while  the  relative  dulness  on  strong  per- 
cussion is  found  a  rib  higher.  On  the  left  side  reso- 
nance extends  in  the  line  of  the  angle  of  the  scapula 
fully  to  the  loth  rib,  though  sometimes  a  tympanitic 
quality  may  be  imparted  by  a  dilated  stomach  or  the 
colon,  or  a  slightly  dull  sound  if  the  spleen  extends  a 
little  further  back  than  usual.  Here  as  elsewhere  on 
the  thorax  there  may  be  slightly  less  intensity  and 
slightly  higher  pitch  on  the  right  side,  on  account  of  the 


52  PHYSICAL    DL4 GNOSIS. 

greater  muscular  development  in  right-handed  persons; 
and  the  effect  of  a  deep  inspiration  in  lowering  the  line 
of  resonance,  and  in  expiration  of  raising  it  an  inch  or 
more,  is  also  to  be  remembered.  In  ordinary  breathing 
the  normal  resonance  posteriorly  passes  at  the  loth  rib 
into  the  absolute  flatness  of  the  lumbar  region. 

The  upper  border  of  the  kidney  below  the  nth  rib, 
the  left  being  a  little  higher  than  the  right,  cannot 
ordinarily  be  separated  by  percussion  from  the  dulness 
of  the  spleen  and  li\-er,  nor  can  the  inner  border  be 
separated  from  the  spinal  column.  The  outer  edge  can, 
however,  be  defined  by  percussion  from  the  colon  on 
the  right  and  the  stomach  and  colon  on  the  left  by 
percussing  outward  from  the  median  line  behind.  The 
outer  border  of  the  kidney  is  three  or  four  inches  beyond 
the  median  line.  The  lower  border  can  sometimes  be 
defined  by  a  line  of  tympany  just  above  the  crest  of  the 
ilium,  produced  in  the  colon.  Forcible  percussion  is 
required,  and  it  is  desirable  to  place  a  pillow  under  the 
abdomen  of  the  patient  lying  prone  upon  his  face. 


ABNORMAL  LUNG  SOUNDS  ELICITED  BY 
PERCUSSION. 

It  goes  without  saying  that  a  sound  which  is  normal 
in  one  situation  becomes  abnormal  when  heard  in  a 
position  unnatural  to  it  in  health,  as  dulness  or  tympany 
below  the  clavicles  or  below  the  angles  of  the  scapulas, 
where  vesicular  resonance  is  ordinarily  found.  But  in 
addition  there  are  certain  positive  modifications  of  nor- 


ABNORMAL  PERCUSSION  LUNG  SOUNDS.        53 

mal  sounds  not  heard  anywhere  in  health,  or  at  least 
under  such  exceptional  conditions  as  do  not  permit  them 
to  be  included  among  normal  sounds. 

These  are  vesiculo-tympanitic  resonance,  am- 
phoric resonance,  and  cracked-pot  sound. 

Vesiculo-tympanitic  Resonance. — The  vesiculo- 
tympanitic resonance  of  Flint  has  already  been  alluded 
to,  but  requires  to  be  further  considered  because  it  is 
not  generally  recognized  by  either  American,  English, 
or  German  authors  as  something  distinct  and  different 
from  tympany,  and  it  requires  to  be  conformed  to  their 
treatment  of  conditions  supposed  to  cause  it.  In  the 
language  of  its  describer,  "  the  resonance  increased  in 
intensity;  the  quality  a  combination  of  the  vesicular 
with  a  tympanitic,  and  the  pitch  higher  in  proportion 
as  the  tympanitic  quality  predominates  over  the  vesicu- 
lar." According  to  him,  also,  the  morbid  condition 
which  especially  illustrates-  this  form  of  resonance  is  the 
over  dilatation  of  the  air  vesicles  which  constitutes  ves- 
icular emphysema  of  the  lungs,  but  he  includes  also  in- 
terstitial or  interlobular  emphysema.  It  occurs  also 
over  the  upper  lobe  of  a  lung  when  the  lower  lobe  is 
solidified  in  the  second  stage  of  pneumonia,  and  over 
the  lower  lobe  when  the  upper  is  solidified.  So,  also,  if 
the  lower  part  of  a  pleural  sac  contains  fluid,  even 
though  the  volume  of  the  lung  is  diminished,  the  upper 
part  of  the  same  lung  may  give  the  same  vesiculo-tym- 
panitic note.  Attention  was  first  called  to  this  by 
Skoda,  and  it  is  known  as  Skoda's  resonance.  Too 
much  of  the  intrathoracic  space  must  not  be  occupied 


54  PH\'SICAL   DIAGNOSIS. 

by  fluid,  because  the  luug  is  thus  compressed  and  ren- 
dered airless.  The  resonance  remains  vesiculo-tympan- 
itic  above  the  liquid  \Yhen  the  latter  is  suificient  to  fill  a 
third,  a  half,  or  even  two-thirds  of  the  intrathoracic 
space. 

Xow,  these  are  essentialh'  the  conditions  named  by 
Da  Costa,  Paul  Niemeyer,  and  Graham  Brown  as  pro- 
ducing tympanitic  resonance  of  lung  tissue.  It  is  well 
described  by  Brown  *  :  "  Just  as  when  the  lung  is  re- 
moved from  the  body  and  allowed  to  collapse  it  gives  a 
tympanitic  note,  so  when  a  similar  retraction  and  re- 
laxation of  the  pulmonic  tissue  takes  place  within  the 
thorax,  that  variety  of  percussion  note  may  be  heard. 
This  is  best  marked  in  cases  of  pleuritic  effusion,  which, 
gravitating  to  the  lower  portion  of  the  cavity,  floats  up 
the  lung  and  causes  relaxation  of  the  upper  portion. 
When  the  effusion  is  small  in  amount  the  tympanitic 
note  can  only  be  detected  over  that  portion  of  the  lung 
which  lies  immediately  above  the  upper  limit  of  the 
fluid,  but  when  the  efltusion  is  considerable  the  whole 
upper  lobe  may  be  tympanitic  on  percussion.  This  is 
also  called  tympany  by  mediate  relaxation.  Similarly, 
effusion  into  the  alveoli  in  pneumonia  or  oedema  may 
produce  a  like  result."  t     This  is  tympany  by  imme- 

*  "  Medical  Diagnosis,"  3d  edition,  Edinburgh,  1887,  page  207. 

+  This  can  occur  only  in  the  first  and  third  stages  of  pneumonia 
when  the  air  vesicles  contain  air,  the  second  stage  being  one  of 
absolute  airlessness  and  dulness. 


ABNORMAL  PERCUSSION  LUNG  SOUNDS.       55 

diate  relaxation.  Nieraeyer*  adds,  occasionally  gan- 
grene and  infarct,  also  disseminated  tubercular  infiltra- 
tion, emphysema,  arid  nervous  asthma,  and  that  portion 
of  the  lung  not  inflamed  but  immediately  adjacent  to  a 
hepatized  part, — another  instance  of  mediate  relaxation. 
In  like  manner  phthisical  consolidations  of  the  apices 
may  also  occasion  an  obscurely  tympanitic  note  over 
neighboring  portions  of  the  lung  by  mediate  relaxation. 
Finally,  Da  Costa,  who  with  Flint  may  be  regarded  as 
representing  the  American  School,  says  :  "  But  gener- 
ally a  tympanitic  sound  over  the  seat  of  the  lungs  is 
expressive  of  emphysema  or  of  pneumothorax,  or  some- 
times of  a  cavity  or  of  oedema  of  the  lungs.  Again,  as 
Skoda  has  taught  us,  it  occurs  in  moderate  pleuritic 
effusions  above  the  level  of  the  liquid."  f 

It  has  seemed  to  me  important  to  contrast  these  state- 
ments, both  in  order  to  give  a  better  idea  of  what  Flint 
intends  to  convey  by  vesiculo-tympanitic  resonance  and 
to  avoid  confusion  in  the  minds  of  those  who  might 
with  reason  be  confused  by  statements  apparently  so 
diverse. 

Pure  Tympanitic  Resonance. — Tympanitic  re- 
sonance is  found  in  normal  thoracic  states  only  over  the 
larynx  and  trachea  and  in  the  left  infra-axillary  region 
from  encroachment  of  a  tympanitic  stomach.  Else- 
where it  becomes  a  sign  of  an  abnormal  state. 

*  "  Grundriss  der  Percussion  uttd  Auscultaiiott."  Zweite  Auf- 
lage.     Erlangen,  1873,  pages  38,  39. 

t  "  Medical  Diagnosis,"  7th  edition,  1890,  page  265. 


56  PHYSICAL   DIAGNOSIS. 

The  fundamental  principle  to  be  remembered  in  con- 
nection with  .tympanitic  sounds  is  that  their  pitch 
depends  inversely  on  the  volume  "of  circumscribed  air 
and  the  transverse  section  of  an  opening  communicat- 
ing with  the  exterior.  In  the  chest,  tympany  is  pro- 
duced by  percussing  over  air-containing  cavities  in  the 
lung  tissue,  suiSciently  near  the  surface  and  sufificiently 
large,  and  whose  wails  are  not  too  tense.  Bearing  in 
mind  the  above  principle,  approximate  estimates  as  to 
size  and  shape  of  cavities  may  be  made  even  by  obser- 
vations as  to  pitch.  Thus  a  cavity  of  small  size  will 
give  a  higher-pitched  tympanitic  note  than  one  of  a 
large  size. 

As  these  cavities  usually  communicate  with  a  bronchus 
they  are  further  characterized  by  differences  in  the  pitch 
when  percussed  with  the  mouth  open  or  closed.  Thus 
is  produced  Wintrich's  change  of  note,  according 
to  which  percussion  over  a  given  cavity  gives  a  higher- 
pitched  tympanitic  sound  with  the  mouth  open  than 
when  it  is  closed.  This  may  be  illustrated  by  percussing 
over  the  thyroid  cartilage  under  the  two  conditions, 
when  the  difference  will  be  very  evident.  It  occurs  in 
connection  with  the  superficially-placed  cavities  in  com- 
munication with  a  bronchus.  If  this  change  of  sound 
is  observed  on  lying  down,  but  is  not  on  sitting  up,  or 
vice  versa,  it  means  that  the  bronchus  leading  to  the 
cavity  is  obstructed  in  the  position  in  which  the  Win- 
trich  change  of  note  does  not  occur.  This  is  the 
interrupted  change  of  note  of  Wintrich. 

By  what  is  known  as  Gerhardt's  change  of  note 


ABNORMAL   PERCUSSION   LUNG   SOUNDS. 


57 


we  learn  something  about  the  shape  of  cavities.  Cavi- 
ties which  have  unequal  diameters,  or  are  oval  in  shape 
and  are  partially  filled  with  fluid,  alter  their  note  on 
changing  the  position  of  the  patient  from  sitting  to 
horizontal.  Thus  suppose  A  to  represent  an  oval  cavity 
in  the  vertical  position  with  the  contained  fluid  at  the 
line  c  d.     If  the  patient  lies  down  the  long  diameter 


Fig.  13. — To  Illustrate  Gerhardt's  Change  of  Note. 


will  become  horizontal,  as  in  B,  and  the  level  of  the 
fluid  will  fall  to  a  b.  The  percussion  note  is  lower 
when  the  longer  diameter  is  horizontal,  higher  when  it 
is  vertical.  If,  therefore,  the  percussion  note  changes 
in  thus  altering  the  position  of  the  patient,  the  cavity 
is  oval. 

Every    cavity  does   not,  of   course,  furnish   the  con- 


5  8  PHYSICAL   DIAGNOSIS. 

ditions  of  tympanitic  percussion.  Recent  experiments 
also  shed  some  doubt  as  to  the  correctness  of  the  law 
originally  announced  by  Gerhardt,  that  the  pitch  of 
oval  cavities  partially  filled  with  fluid  depends  on  the 
direction  of  the  greater  diameter,  while  other  conditions, 
too,  have  been  suggested  as  capable  of  explaining  the 
differences  of  pitch  observed  in  cavities  whose  relations 
have  been  altered  by  changes  in  the  patients'  position. 

Second,  pure  tympanitic  resonance  is  also  character- 
istic of  pneumothorax  if  the  distension  is  not  too  great. 
There  being  no  free  communication  of  such  a  space  with 
a  bronchial  tube,  no  change  of  pitch  occurs  when  per- 
cussing with  the  mouh  open  and  closed.  If  there  hap- 
pens to  be  liquid  in  the  sac,  Biermer's  change  of 
note  may  be  produced  as  follows  :  In  the  vertical  posi- 
tion of  a  pneumothorax  containing  fluid  the  cavity  is 
larger  because  the  weight  of  the  fluid  pushes  the  dia- 
phragm downward.  Hence  in  this  position  the  pitch 
is  lower.  If  the  position  of  the  patient  is  now  changed 
from  the  vertical  to  the  horizontal,  the  cavity  becomes 
smaller  by  reason  of  the  changed  position  of  the  fluid 
and  the  pitch  becomes  higher. 

Third,  a  pure  tympanitic  resonance  may  be  produced 
in  pneumonia  when  the  portion  of  the  lung  lying 
between  the  trachea  or  primary  bronchi  and  the  surface 
becomes  hepatized.  This  is  sometimes  called  Williavis' s 
tracheal  resonance,  and  is  most  frequently  found  in  the 
first  or  second  intercostal  space  near  the  sternum.  A 
pleuritic  effusion  may  compress  the  lung  into  a  like 
position,  at  which  a  like  note  may  be  produced. 


ABNORMAL   PERCUSSION   LUNG   SOUNDS.  59 

Amphoric  Resonance. — Amphoric  resonance,  a 
variety  of  tympanitic  resonance,  is  a  high-pitched  me- 
tallic' resonance,  so  called  from  its  resemblance  to  the 
sound  produced  by  striking  the  side  of  a  jar,  either 
empty  or  containing  a  small  quantity  of  fluid.  It  may 
also  be  imitated  by  filliping  the  cheeks  when  the  mouth 
is  distended  with  air.  It  has  an  echoing  sound,  the  waves 
being  reflected  from  side  to  side  of  the  closed  vessel,  as 
is  speech  in  a  vaulted  chamber.  A  modification  or 
variety  of  amphoric  resonance  is  the  coin-clinking 
test  of  Gairdner,  or  Bell  tympany  or  bell-metal 
sound,  in  which  a  coin  of  sufiicient  size  used  as  a  plexi- 
meter  is  percussed  by  another  on  the  anterior  surface  of 
the  chest,  while  the  auscultator  listens  posteriorly  or  vice 
versa.  The  sound  thus  elicited  usually  resembles  that 
produced  by  striking  with  a  hammer  on  an  anvil ;  more 
rarely  it  is  softer  and  more  musical.  It  is  especially 
characteristic  of  pneumothorax. 

Amphoric  resonance  is  not  very  often  met ;  the  con- 
ditions of  its  production  in  the  human  body  are  an  air- 
filled  cavity  of  considerable  size,  with  firm  and  smooth 
walls,  completely  closed  or  communicating  with  the  air 
by  a  small  opening  only.  When  thus  communicating  it 
is  louder  when  the  mouth  is  kept  open.  These  condi- 
tions are  fulfilled  by  certain  phthisical  cavities,  and 
especially  by  pneumothorax  or  pyopneumothorax,  some- 
times also  by  a  distended  stomach.  If  with  a  pyopneu- 
mothorax the  body  be  shaken,  a  splashing  or  succus- 
sion  occurs,  which  will  sometimes  have  the  same  ringing 
character.  The  same  conditions  are  sometimes  fulfilled 
by  a  distended  stomach  containing  fluid. 


6o  PHYSICAL   DL4GNOSIS. 

The  Cracked-pot  Sound. — This  sound  is  well 
named  because  it  quite  resembles  that  produced  bj^  tap- 
ping a  cracked  jar,  and  is  therefore  one  of  tbe  most 
distinctive  and  easily  recognized  of  the  abnormal  per- 
cussion sounds.  It  is,  too,  a  modification  of  tympanj', 
and  is  caused  by  the  explosion  of  air  from  a  cavity 
through  a  small  opening  by  a  sudden  forcible  blow.  It 
is  also  imitated  in  mechanism  as  weU  as  character  by 
suddenly  striking  the  back  of  the  two  palm-apposed 
hands  against  the  knee,  after  the  method  used  by  boys 
to  imitate  the  chnking  of  coins. 

It  may  also  be  made  by  striking  the  pleximeter  when 
the  latter  is  not  closely  apphed  to  the  skin,  an  accident 
favored  by  a  hairy  skin.  The  cracked-pot  sound  may 
also  sometimes  be  produced  in  the  normal  chest  by 
percussing  it  sharply  while  the  patient  is  in  the  act  of 
speaking  or  crying  out,  the  narrow  glottis  affording  the 
condition  of  a  small  opening.  This  ma}^  more  readily 
be  done  under  these  conditions  in  children  who  have 
thin,  elastic  chest-walls. 

The  cracked-pot  sound  is  produced  in  disease  by  per- 
cussing over  a  ca'vity  which  affords  the  conditions 
named,  vis.,  a.  somewhat  superficial  position,  sufficiently 
pelding  walls,  and  communication  by  a  small  opening 
with  a  bronchial  tube  and  thence  with  the  outside  air. 
It  is  the  most  infallible  sign  of  a  ca\Tty  known.  In 
producing  it,  the  mouth  of  the  patient  is  kept  open  and 
a  sudden  forcible  blow  of  the  plexor  given.  Often  it 
caiuiot  be  heard  unless  the  ear  is  attentively  turned  near 
the  chest  to  catch  the  sound.     The  same  conditions 


AUSCULTATION.  6 1 

exist  in  a  pneumothorax  with  a  thoracic  fistula  into  the 
lung,  and  under  these  circumstances  a  cracked-pot 
sound  may  be  produced  by  percussing  such  a  chest  in 
the  manner  described. 


AUSCULTATION. 

Auscultation  is  the  act  of  listening  to  sounds,  more 
particularly  those  produced  in  the  chest  by  breathing 
or  speaking,  or  by  the  heart's  action,  or  in  the  blood- 
vessels ;  to  these  sounds  as  modified  by  disease  and 
to  certain  new  sounds  produced  by  disease.  In  so 
doing  the.  ear  is  applied  either  directly  to  the  chest  or 
on  an  instrument  known  as  a  stethoscope.  According 
as  this  instrument  is  employed  or  not,  the  auscultation 
is  mediate  or  immediate.  Both  have  their  advan- 
tages. When  it  is  desired  to  isolate  or  circumscribe  a 
sound,  especially  in  the  study  of  the  heart,  the  stetho- 
scope helps  us  greatly,  while  in  the  study  of  more  diffuse 
sounds,  as  many  of  those  produced  in  the  lungs,  the 
direct  application  of  the  ear  to  the  chest  is  generally  to 
be  preferred.  The  stethoscope  becomes  also  desirable 
in  the  examination  of  patients  not  especially  clean. 
In  inexperienced  hands,  on  the  other  hand,  the  patient 
is  often  rendered  uncomfortable  by  undue  pressure  by 
the  head  on  the  instrument. 

The  stethoscope  was  invented  and  used  by  Laennec, 
of  Paris,  in  1816,  in  its  single  shape.  Through  the 
labors  of  Laennec,  by  the  aid  of  the  stethoscope  the 
diagnosis  of  diseases  of  the  chest  developed  in  a  com- 


62 


PHYSICAL    DLVGXOSIS. 


paratively  short  space  of  time  to  an  accuracy  scarcely 
equaled  in  the  case  of  any  other  set  of  organs.  The 
binaural  instrument  was  devised  by  Cammann,  of  New 
York  city,  in  1840.  There  can  be  no  doubt  that,  with 
the  latter,  sounds  are  more  loudly 
heard.  On  the  other  hands,  all  noises, 
as  that  of  the  rubbing  of  linen  or 
clothing,  are  so  much  exaggerated 
that  the  beginner  is  often  confused. 
The  double  instrument  is  becoming 
more  popular  of  late,  but  preference 
depends  on  training.  A  man  who  has 
been  brought  up  to  use  the  double 
stethoscope  soon  grows  to  prefer  it, 
while  he  who  is  trained  to  the  single 
instrument  would  not  have  the  dou- 
ble. When  either  form  of  the  instru- 
ment is  used,  better  results  are  ob- 
tained when  the  chest-end  is  applied 
directly  to  the  bare  skin,  whereas  in 
immediate  auscultation  it  is  desirable 
that  there  should  be  a  thin,  soft 
towel,  or  some  thin  garment,  inter- 
posed between  the  ear  and  the  skin. 
The  ear  or  stethoscope  should  also  be  applied  closely  to 
the  chest- wall,  so  as  to  become  a  part  of  it  or  continuous 
with  it ;  and  yet,  as  stated,  the  stethoscope  may  be 
applied  too  strongly,  so  as  to  give  pain  to  the  patient. 
Successful  auscultation  requires  that  the  attention  should 
be  closelv  concentrated  on  the  matter  in  hand. 


Fig 


14.  —  Hawksley's 
Stethoscope. 


AUSCULTATION. 


63 


The  single  stethoscope  is  made  of  wood  or  metal. 
That  originally  made  by  Hawksley,  of  London,  out  of 
gun-metal,  and  provided  with  a  detachable  hard  rubber 


Fig.  15. — Sansom's  Binaural 
Stethoscope. 


Fig.  16. — Simpler  Form  of  Sansom's 
Binaural  Stethoscope. 


ear  piece,  shown  in  Fig.  14,  is  the  most  convenient  and 
neatest.  A  large  variety  of  double  stethoscopes  has 
been  suggested.     The  double  instrument,  Fig.  15  in  the 


64 


PHYSICAL   DLA.GN0S1S 


text,  partly  metal  and  partly  rubber  tubing,  was  devised 
by  Sansom,  and  is  ver}'  conveni- 
ently carried  when  folded  at  the 
joint.  It  is  especially  suitable 
when  the  patient  is  inaccessibly 
placed  in  relation  to  the  exam- 
iner, an  advantage  possessed  in 
various  degrees  by  all  binaural 
stethoscopes  over  the  single  in- 
strument. A  still  simpler  form  is 
shown  in  Fig.  i6.  In  selecting 
this  shape,  great  care  should  be 
taken  to  secure  an  ear-piece  which 
fits  the  ear  properly ;  also, that  the 
rubber  tubing  embraces  closely 
the  metallic  chest-portion  as  well 
as  the  ear  pieces,  and  if  tubing 
happen  to  become  split,  the  spht 
end  can  be  cut  off  and  the  tube 
reapplied. 

Recently  Dr.  H.  K.  Valentine, 
of  Brooklyn,  N.  Y.,  has  devised  * 
a  binaural  stethoscope,  which  in 
m)'-  experience  conducts  stetho- 
scopic  sounds  more  loudly  to  the 
ear  than  any  other  I  have  used. 
The     instrument     (Fig.     17)     is 

composed    of    hard   rubber,  the  chest-  and   ear-  pieces 


Fig.  17. — Valentine's  Bin- 
aural Stethoscope. 


*  A'.  V.  Med.  Record,  July  16,  1892. 


AUSCULTATION    OF    THE    NORMAL    LUNG.  65 

being  united  by  two  pieces  of  ordinary  soft-rubber 
tubing,  each  about  3^  inches  in  length,  and  being 
flexible  the  instrument  may  be  folded  and  carried 
in  the  pocket.  The  bell  consists  of  two  parts,  the 
lower  a  tube  4^  inches  long,  having  ^  inch  at  the 
mouth  and  ^  inch  at  the  upper  end,  where  it  is  screwed 
into  the  upper  section.  This  top  section  is  ^  inch 
long  and  has  two  canals,  each  y^  inch  in  diameter, 
diverging  from  it,  separated  at  their  origin  by  a  septum 
of  hard  rubber.  The  ear-pieces  are  straight  up  to 
where  they  are  curved  to  enter  the  ear,  having  a  bore 
of  }l  inch  at  the  lower  end,  tapering  to  ^  at  the  ear 
ends.  These  are  retained  in  the  ear  by  a  flat  steel 
spring.  When  the  instrument  is  in  use,  the  waves. of 
sound  pass  upward  through  the  long  bell,  divided  at  the 
top  by  the  sharp  rubber  septum,  and  thence  through  the 
ear-pieces  into  the  ears  of  the  operator.  The  efficiency 
of  the  instrument  depends  largely  on  the  smooth  finish 
of  the  interior  of  the  hard-rubber  tubing  throughout  its 
entire  length.  It  is  provided  with  one  or  two  accessory 
soft-rubber  bells,  also  figured,  which  intensify  the 
sounds,  but  the  instrument  is,  for  the  most  part,  best 
used  without  them. 

When  the  interior  of  the  bell  becomes  very  dusty,  it 
may  be  easily  cleaned  by  allowing  cold  water  to  run 
through  it. 

AUSCULTATION  OF  THE  NORMAL  LUNG. 

The  breathing  sounds  in  health  are  separable  into 
two  distinct  orders :  first,  the  bronchial  breathing ; 


66  PHYSICAL    DL4GN0SIS. 

second,  vesicular  murmur  or  respiratory  mur- 
mur. Both  are  normal  sounds,  constantly  produced 
in  the  act  of  breathing,  but  in  certain  parts  of  the  chest 
one  is  heard  more  or  less  to  the  exclusion  of  the  other. 
Thus  the  vesicular  breathing  is  heard  in  its  most  typical 
character  under  the  left  clavicle,  where  it  is  best  studied 
by  immediate  auscultation. 

Bronchial  respiration  is  the  easiest  of  description. 
It  is  blowing  or  tubal  in  quality,  both  in  inspiration 
and  expiration,  and  the  two  parts  are  nearly  equal  in 
length,  the  expiratory  being  often  shghtly  the  longer. 
It  is  heard  in  its  purest  form  over  the  larynx  and  trachea, 
but  cflso  quite  pronouncedly  between  the  scapulee  at  the 
root  of  the  lungs,  where,  however,  it  is  more  or  less 
admixed  with  vesicular  breathing.  The  pitch  is  high  in 
both  in-  and  out-breathing,  and  somewhat  higher  in  the 
latter.  It  is  caused  primarily  in  the  glottis  by  vibra- 
tions produced  in  the  column  of  air  as  it  passes  the 
vocal  cords  in  inspiration  and  expiration.  It  is  con- 
ducted downward  from  the  larynx  partly  along  the  solid 
walls  of  the  trachea  and  bronchi  and  partly  by  air,  the 
latter  being  chief  conductor.  It  is  modified  as  the 
tubes  gradually  reduce  their  calibre. 

Vesicular  murmur  is  the  breathing  sound  heard 
when  listening  over  the  vesicular  tissue  of  the  lung.  It 
is  also  divided  into  two  portions — the  inspiratory  and 
expiratory,  the  in-  and  out-murmur,  the  former  being 
much  the  longer.  Perhaps  no  language  can  give  a 
correct  notion  of  the  vesicular  murmur,  but  it  is  a  soft, 
low-pitched  sound,  said   to    resemble   the  sighing  of  ^ 


AUSCULTATION    OF    THE    NORMAL    LUNG.  67 

gentle  breeze  through  the  leaves  of  a  tree.  It  is  the 
blowing  sound  primarily  produced  in  the  glottis,  sub- 
dued and  muffled  by  distance  and  the  spongy  structure 
of  the  lung.  When  typical  the  inspiratory  murmur 
is  much  longer  than  the  expiratory.  The  ratio  is, 
however,  not  fixed.  The  expiration  may  be  one-fourth 
as  long,  or  it  may  be  a  mere  whiff,  as  it  were.  It 
represents  the  recoil  of  the  air  vesicles  and  the  back- 
ward movement  of  the  air.  The  question  why  the 
expiratory  murmur  is  less  loud  and  shorter  than  the 
inspiratory  is  a  natural  one.  It  is  probably  because  sound 
is  better  conducted  in  the  direction  of  the  movement 
of  the  vibrating  column  from  the  point  at  which  the 
vibration  is  caused,  /.  e.,  in  this  instance  at  the  glottis. 
During  inspiration  the  sound  is  conducted  toward  the 
periphery  and  during  expiration  toward  the  glottis. 

The  vesicular  murmur  is  not  everywhere  the  same, 
even  in  health.  As  a  rule,  it  is  slightly  louder,  more 
purely  vesicular  below  the  left  clavicle,  and,  assuming  it 
to  be  typical  in  this  situation,  is  nearest  maintained  in 
the  axilla  and  below  the  scapulas.  Under  the  right 
clavicle  the  slightest  rise  in  pitch  and  a  distinct  pro- 
longation of  the- expiratory  portion  is  often  noted,  and 
to  be  remembered  as  of  great  importance  in  diagnosis 
in  doubtful  cases.  This  is  usually  ascribed  to  an  ad- 
mixture of  the  bronchial  element  due  to  the  larger  size 
of  the  right  bronchus,  and  of  its  branches  sent  up  toward 
the  right  clavicle.  Over  the  scapular  regions  posteriorly 
the  vesicular  murmur  is  less  intense,  because  of  the 
thickness  of  the  bone  and  muscles,  but  the  same  differ- 


68  PHYSICAL   DIAGNOSIS. 

ence  between  the  two  sides  may  sometimes  be  noted  in 
the  supraspinous  fossse,  as  below  the  clavicles  in  front. 
For  the  same  reason  it  is  less  intense  in  the  mammary 
regions,  and  in  all  fat  and  muscular  persons  as  compared 
with  the  thin  and  emaciated.  Between  the  angles  of 
the  scapulae  still  more  of  the  bronchial  element  is  added 
than  below  the  right  clavicle,  and  the  sound  is  de- 
cidedly more  blowing  and  the  expiration  longer.  It  is 
to  be  remembered  that  both  vesicular  and  bronchial 
breathing  are  being  constantly  produced  in  the  lungs, 
but  that  in  certain  situations  one  overshadows  the  other, 
partly  because  of  its  proximity  immediately  under  the 
point  where  the  ear  is  applied,  and  partly  because  the 
normal  lung  is  a  poor  conductor  of  sounds. 

ABNORMAL     MODIFICATIONS     OF    BREATHING 
SOUNDS. 

Changes  in  the  Vesicular  Murmur. — The  vesi- 
cular murmur  is  modified  by  diseased  states  as  follows  : 

1.  It  is  jerking  or  interrupted. 

2.  It  is  increased  in  intensity  or  loudness. 

3.  It  is  diminished  in  intensity,  feeble,  more  indis- 
tinct. 

4.  It  is  altogether  absent. 

5.  It  is  commingled  with  bronchial  breathing,  by 
which  a  harsher  sound  is  produced,  and  of  altered  rhythm. 

6.  It  is  substituted  by  bronchial  breathing. 

I.  Interrupted  or  jerking  or  cogwheel  breath- 
ing is  the  least  important  of  the  alterations  in  the 
vesicular   murmur,  being  generally  of   no   significance. 


ABNORMAL    BREATHING    SOUNDS.  69 

Such  is  its  value  in  persons  who  are  nervous  or  sHghtly 
alarmed  during  examination.  The  interruption  affects 
most  frequently  the  inspiratory  act,  but  it  may  occur  in 
either  or  both,  and  the  act  may  be  broken  into  two  or 
three  parts.  More  serious  is  its  cause  when  it  occurs  in 
connection  with  severe  pleurisy  or  pleurodynia,  where 
the  pain  of  the  act  of  breathing  causes  the  latter  to  be 
interrupted.  Finally,  it  may  be  present  in  incipient 
tuberculosis  or  emphysema,  but  even  here  its  diagnostic 
value  is  merely  confirmatory,  and  that  only  when  it 
persists. 

2.  Vesicular  breathing  is  exaggerated  or  supple- 
mental, or  increased  in  intensity  by  any  cause  which 
compels  the  lung  or  a  part  of  it  to  assume  increased 
function.  This  happens  in  one  lung  or  a  part  when 
the  other  or  the  remainder  is  deprived  of  its  use  by 
compression  or  destruction.  In  this  change  both  the 
inspiratory  and  expiratory  factors  are  proportionally 
increased  in  loudness  and  in  length.  Its  pitch  is  unal- 
tered. From  the  resemblance  of  this  exaggerated  breath- 
ing, as  it  is  also  called,  to  the  louder,  normal  breathing  in 
children  it  is  often  called  puerile  breathing. 

3.  The  vesicular  murmur  is  feeble  or  diminished  in 
intensity  by  various  causes.  The  quieter  the  breathing 
the  less  loud  its  sounds,  and  diminished  loudness  may  be 
due  to  feebleness  in  the  inspiratory  act  from  debility,  or 
to  obstruction  in  the  bronchus  leading  to  the  ausculted 
area.  More  commonly,  in  actual  practice,  the^feeble- 
ness  is  due  to  the  interposition  of  a  liquid  or  a  solid 
medium    between    the    lungs' [and    theyear,^such  as 'a 


d 


70  PHYSICAL   DL4GN0SIS. 

pleuritic  eflusion  or  the  plastic  exudation  of  a  pleurisy. 
Or  it  is  due  to  the  filling  up  of  the  air  vesicles  hy  an 
exudate,  as  in  pneumonia,  or  tubercular  infiltration  in 
phthisis.  More  frequentl_v  it  is  obliterated  by  these 
causes. 

4,  The  vesicular  murmur  is  absent  or  altogether  re- 
moved by  the  higher  degrees  of  the  last-named  condi- 
tions, viz.,  pleuritic  effusion,  pneumonic  and  tubercular 
infiltrations. 

5.  The  vesicular  murmur  is  altered  by  the  addition 
of  a  bronchial  element,  the  first  effect  of  which  is  to 
lengthen  the  expiratory  factor  of  the  breathing  sound, 
to  alter,  in  a  word,  its  rhythm.  Coincidently  with,  or 
immediately  succeeding  upon  this,  is  a  roughening  of 
both  inspiration  and  expiration,  at  first  slight  and  then 
positive.  As  long  as  this  degree  is  maintained  there  is 
still  a  vesicular  factor  in  the  breathing,  whence  it  was 
named  by  Flint  broncho-vesicular  breathing.  It  has 
also  been  called  indeterminate  breathing.  Expressive 
terms  are  also,  harsh  respiration,  7-i/de  respiration,  or 
rough  respiration.  Such  niodifications  of  normal  breath- 
ing are  brought  about  by  an  infiltration  of  a  certain 
number  of  air  vesicles  with  solid  material,  while  others 
still  niaintain  their  function.  The  effect  of  this  is  also 
to  iniprove  the  conducting  power  of  the  portion  of  the 
lung  involved,  so  that  it  becomes  a  better  conductor  of 
the  bronchial  sounds  elsewhere  produced,  which  are 
thus  brought  to  the  ear.  It  means,  therefore,  that  a 
certain  small  extent  of  consolidation  has  taken  place. 

How   shall  we  distinguish   between  puerile  breathing 


ABNORMAL    BREATHING    SOUNDS.  71 

and  broncho-vesicular  breathing,  a  most  important  re- 
quirement, since  they  indicate  opposite  conditions? 
Yet  there  is  a  certain  similarity  between  them  which 
inexperienced  observers  may  mistake  for  identity,  and 
which  even  an  experienced  man  may  sometimes  have 
occasion  to  dwell  on  before  deciding.  Both  are  louder 
and  rougher  as  to  inspiration,  but  vastly  different  is  the 
manner  in  which  expiration  is  influenced.  In  puerile 
breathing  it  may  be  slightly  longer  and  more  distinct 
than  in  health,  but  it  maintains  its  ratio  to  the  length 
of  the  inspiratory  murmur.  Not  so  is  it  with  rude 
respiration.  Here  the  expiratory  sound  is  roughened 
and  prolonged  out  of  all  proportion  to  the  inspiratory. 
And  in  catching  slight  degrees  of  difference  the  atten- 
tion must  be  concentrated  on  the  expiratory  murmur. 
If  it  is  greatly  prolonged  in  proportion  to  the  inspira- 
tory, so  as  to  nearly  or  quite  equal  it,  and  at  the  same 
time  harsher  than  in  health,  not  simply  loud-er,  then  we 
have  broncho-vesicular  breathing  and  the  conditions 
which  produce  it.  And  if  to  this  is  added  a  slight  rise 
of  pitch  on  percussion,  a  slight  dulness,  the  condition 
is  confirmed.  Sometimes,  however,  these  conditions  do 
not  go  entirely  pari  passu.  Then  we  must  wait  and 
watch.  We  must  not  forget,  too,  the  physiological  dif- 
ferences on  the  two  sides,  that  there  is  the  slightest 
higher  pitch  on  the  right  in  both  percussion  note  and 
breathing  sound,  and  that  the  expiratory  murmur  is 
blightly  longer  on  the  right.  The  difficulties  are  in- 
creased by  the  physiological  variations  in  the  vesicular 
murmur,  which  are  not  to  be  overlooked. 


72  PHYSICAL   DL4.GN0SIS. 

6.  The  expiratory  vesicular  murmur  is  prolonged 
in  emphysema  because  of  the  loss  of  elasticity  of  the 
air  vesicles  resulting  in  a  slowing  of  the  expiratory  act. 

7.  Finally,  the  vesicular  murmur  may  be  altogether 
substituted  by  bronchial  breathing.  This  means 
that  a  considerable  area  of  lung  has  become  obhterated 
as  to  its  vesicular  structure,  and  has  thus  also  become 
an  excellent  conductor  of  the  distant  normal  bronchial 
breathing,  which  is  heard  with  a  blowing  tubal  quality 
as  though  produced  directly  under  the  ear.  Again,  it 
is  to  be  remembered,  that  there  is  no  more  bronchial 
breathing  produced  under  these  circumstances  than  there 
was  before  the  consolidation  took  place.  It  is  simply 
that  the  vesicular  murmur  has  altogether  vanished  for 
the  reason  named,  and  therefore  cannot  longer  mask  the 
bronchial  breathing,  while  the  latter  also  is  better  con- 
ducted to  the  ear.  iVcute  croupous  pneumonia  furnishes 
the  most  characteristic  bronchial  breathing.  Between 
this  and  broncho-vesicular  breathing  there  is  every  degree, 
depending  upon  the  degree  of  destruction  of  vesicular 
tissue  and  the  extent  of  consolidation.  When  the  con- 
solidation is  very  intense  the  bronchial  breathing  is 
rendered  more  intense,  more  metallic  even  than  the 
tracheal  breathing  sound,  which  may  be  regarded  as  the 
type  of  bronchial  breathing  in  disease,  the  latter  resem- 
bling more  the  tracheal  sound  as  heard  in  health  than 
the  sound  heard  over  the  bronchial  tubes. 


ABNORMAL  BREATHING  SOUNDS,  73 

Varieties  of  Bronchial  Breathing. — Bronchial 
breathing  is  low  pitched  or  high  pitched  according  as 
the  tubes  whence  the  sound  is  conveyed  by  the  consoli- 
dated lung  are  large  or  small. 

Low-pitched  bronchial  breathing  is  also  heard  over 
cavities  of  moderate  size,  when  it  is  called  cavernous 
breathing.  The  expiration  in  cavernous  breathing  is 
also  commonly  lower  pitched  than  the  inspiration, 
reversing,  in  this  respect,  the  bronchial  breathing, 
although  this  is  not  constant  enough  to  be  made  a  rule 
of  difference.  The  conditions  of  its  production  are  a 
cavity  with  yielding  and  resiUent  walls,  by  the  collapse 
of  which  the  air  can  be  forced  out,  since  the  sound  de- 
pends upon  the  entrance  and  exit  of  air.  It  is  also  often 
associated  with  gurgling,  or  may  alternate  with  it.  It 
may.  disappear  to  reappear  after  copious  expectoration. 
Cavities  at  the  apex  of  the  lung  in  tubercular  consump- 
tion are  the  most  common  causes,  but  whatever  produces 
an  excavation  of  the  kind  may  cause  it.  A  dilated 
bronchus,  an  abscess,  and  even  gangrene  of  the  lung 
may  be  such  a  cause. 

High-pitched  bronchial  breathing  is  heard  when  the 
lung  about  smaller  bronchial  tubes  is  consolidated,  as 
often  occurs  in  pneumonia,  which  affords  the  most 
frequent  site  of  bronchial  breathing.  The  term  tubular 
breathing  is  reserved  by  some  for  such  high-pitched 
breathing,  while  others  use  the  terms  bronchial  and 
tubular  as  synonymous. 

Amphoric  Breathing. — Amphoric  breathing  is 
more  easily  recognized  from  its  ringing  metallic  char- 


74  PHYSICAL   DIAGNOSIS. 

acter,  like  that  of  the  amphoric  percussion  note,  resem- 
bling also  the  sound  produced  by  blowing  upon  the 
mouth  of  a  bottle.  It  is  produced  by  the  same  condi- 
tions, a  cavity  with  firm  walls — a  large  cavity.  It  is 
likewise  a  blowing  sound,  of  high  or  low  pitch,  inspira- 
tory or  expiratory,  or  both.  It  is  an  echoing  sound. 
Clinically  its  presence  most  frequently  means  pneumo- 
thorax, but  a  phthisical  cavity  may  rarely  furnish  the 
same  conditions.  Every  case  of  pneumothorax  does 
not,  however,  produce  it,  since  there  must  be  a  perfora- 
tion of  the  pleura  above  the  level  of  the  fluid  and  free 
communication  with  a  bronchial  tube. 

There  are  other  modifications  of  bronchial  breathing 
more  or  less  accidental  and  therefore  of  less  importance. 
Thus  it  sometimes  happens  that  either  the  inspiratory 
or  the  expiratoiy  portion  is  absent,  when  the  peculiar 
breathing  may  be  still  recognized  by  the  pitch  and 
quality  of  the  portion  remaining  cavernous.  Again,  we 
may  have  a  vesicular  inspiration  with  a  cavernous  expira- 
tion {I'esiculo-caveimoiis  respiration) ,  or  there  may  be  an 
admixture  of  cavernous  and  pure  bronchial  breathing 
(^broncho-cavernous) .  In  the  latter,  the  sound  of  expira- 
tion is  bronchial,  high  pitched,  and  is  said  to  indicate  a 
cavity  situated  near  consolidated  lung.  In  the  vesiculo- 
cavernous breathing  the  cavity  is  surrounded  by  a  com- 
paratively intact  pulmonary  tissue  which  produces  an 
admixture  of  sound. 

Another  variety  of  modification  is  the  Seitz-meta- 
morphosing  respiration,  in  which    the    inspiratory 


AUSCULTATION    OF   THE   NORMAL   VOICE.  75 

sound  is  heard  for  about  one-third  of  its  time  as  harsh 
tubal  and  the  remainder  is  of  ordinary  blowing,  cavern- 
ous, or  amphoric  quality.  It  is  said  to  be  caused  by  air 
entering  a  cavity  through  a  narrow  opening. 

AUSCULTATION   OF  THE  NORMAL  VOICE. 

Normal  Vocal  Resonance. — When  the  ear  is  ap- 
plied below  the  clavicle  of  a  person  speaking,  a  confused 
monotonous  humming  sound  is  produced,  of  slight  in- 
tensity and  low  pitch.  In  the  aged,  it  is  apt  to  be 
tremulous  or  somewhat  bleating.  This  is  normal  vocal 
resonance.  It  varies,  however,  in  intensity  and  pitch 
in  different  persons,  being  almost  inaudible  in  some. 
It  depends  also  somewhat  upon  the  manner  in  which 
the  person  speaks  and  the  words  he  utters.  It  is  in- 
creased not  so  much  by  loud  speaking  as  speaking 
"  from  the  chest."  It  is  better  noted  also  if  the  patient 
counts  "  one,  two,  three,"  or  speaks  the  word  "  ninety- 
nine."  It  is  also  feebler  in  women  than  in  men.  It  is 
accompanied  by  a  fremitus  which  is  the  same  as  that 
described  under  palpation.  It  is  a  tactile  fremitus  in 
M'hich  the  ear  is  the  touching  part  instead  of  the  palm 
of  the  hand. 

Vocal  resonance  varies  in  different  parts  of  the  chest, 
being  more  marked  where  the  walls  are  thin.  Hence 
below  the  clavicles  it  is  relatively  loud,  and  more  so 
below  the  right,  just  as  is  tactile  fremitus,  an  important 
fact  to  be  remembered  in  diagnosis,  as  well  as  that 
everywhere  on  the  right  side  it  may  be  more  marked. 
Toward  the  sternal  portion  of  the  clavicular  region  it  is 


76  PHYSICAL   DIAGNOSIS. 

louder,  the  tracheal  voice  influencing  it.  Below  the 
clavicles  it  diminishes  with  the  greater  thickness  of  the 
chest-walls  of  the  mammary  region,  it  is  again  more 
marked  in  the  axillae,  less  intense  over  the  scapulae  and 
louder  below  them.  Between  the  scapulae  it  is  also  in- 
tense. 

The  whispering  voice  also  requires  some  allusion. 
It  being  borne  in  mind  that  whispering  in  most  persons 
is  an  act  of  expiration,  if  the  ear  is  applied  to  a  thin- 
walled  portion  of  the  chest,  as  that  below  the  clavicle, 
and  the  patient  is  asked  to  count  in  a  whisper,  there  is 
heard  a  feeble,  low-pitched  blowing  sound,  unaccom- 
panied by  fremitus,  with  a  pitch  and  quality  the  same  as 
those  of  the  expiratory  vesicular  sound  in  breathing. 
All  that  has  been  said  of  vocal  resonance,  as  to  its 
audibleness  and  the  degree  thereof  in  different  persons 
and  on  the  different  parts  of  the  chest,  is  true  of  the 
"  normal  bronchial  whisper,"  as  it  is  called  by  Flint, 
because  "  the  conduction  of  the  sound  produced  by  the 
whispered  voice  must  be  chiefly  by  the  air  contained  in 
the  bronchial  tubes." 

Normal  Bronchophony. — When  the  stethoscope 
is  placed  over  the  thyroid  cartilage  of  the  larynx  of  a 
person  speaking,  a  much  louder  resounding  soimd  is 
heard  directly  under  the  ear,  accompanied  also  by  a 
thrill  or  fremitus  conveyed  to  the  ear.  But  it  is  still 
confused  and  no  articulate  vrords  are  heard.  It  corre- 
sponds to  bronchial  respiration,  as  normal  vocal  reso- 
nance accords  with  vesicular  breathing. 

If  the  person  thus  auscultated  over  the  larynx  or 
trachea  whispers  instead  of  speaks  audibly,  a  high-pitch 


AUSCULTATION    OF   THE    VOICE.  77 

tubal  sound  accompanied  by  feeble  fremitus  is  heard. 
It  is,  in  fact,  the  expiratory  breathing  sound,  as  heard 
in  these  air  tubes,  interrupted  by  the  act  of  speech. 

Abnormal  Modifications  of  the  Ausculted 
Voice. — The  association  of  a  corresponding  degree  of 
vocal  resonance  with  normal  vesicular  breathing  and  of 
bronchophony  at  the  seat  of  normal  bronchial  breathing 
has  been  referred  to.  The  same  relation  exists  in 
pathological  conditions.  Thus  any  increase  in  the 
intensity  of  the  normal  vocal  resonance  implies  a  cor- 
responding condensation  of  lung  tissue,  culminating  in 
typical  bronchophony  when  the  consolidation  is  com- 
plete, just  as  the  normal  vesicular  breathing  passing 
through  bronchovesicular  terminates  in  bronchial  breath- 
ing. Pari  passu  with  increased  vocal  resonance  and 
bronchovesicular  breathing  goes  increased  bronchial 
whisper. 

Pectoriloquy. — In  addition  there  are  certain  special 
modifications  of  the  normal  vocal  resonance  correspond- 
ing more  or  less  to  certain  morbid  states.  Thus  there 
is  the  cavernous  voice  or  pectoriloquy,  in  which  articu- 
late speech  is  heard  as  though  coming  directly  from  the 
chest  into  the  ear.  While  this  is  commonly  the  sign  of 
a  cavity  of  some  size,  it  is  not  always  so,  the  voice  being 
similary  transmitted  by  solidified  or  collapsed  lung,  a 
tumor  of  the  lung,  and  over  the  upper  lobe  of  a  lung 
whose  lower  lobe  is  compressed  by  a  pleuritic  effusion. 
Whispering  pectoriloquy,  in  which  whispered  articulate 
speech  is  conveyed  to  the  ear,  is  a  much  more  rehable 
sign  of  a  cavity. 


78  PHYSICAL   DLA.GNOSIS. 

Amphoric  voice  is  ringing  and  metallic,  echoing 
like  the  other  amphoric  sounds,  and  like  them  indicates 
the    same    conditions — a   large   cavity  with   firm   walls. 

^gophony  is  another  ver}'  distinctive  modification 
of  bronchophony.  It  is  admirably  likened  to  the  bleat- 
ing of  a  goat,  and  is  produced  during  speech  when  there 
is  a  thin  layer  of  liquid  between  the  chest-wall  and  the 
lung,  in  pleuritic  effusions,  or  when  there  is  liquid  in 
the  chest  cavity  from  other  causes.  It  is  most  frequently 
heard  behind  at  about  the  angle  of  the  scapula  or  some- 
what anterior  to  this.  It  is  said  to  be  produced  in 
flattened  air  tubes  of  moderate  size  whose  calibre  is 
constantly  changing  in  size  during  speech.  It  is  not 
confined  to  the  condition  just  named,  but  may  occur 
over  any  superficial  area  of  collapsed  lung,  whether 
caused  by  effusion  or  false  membrane. 

Diminished  Vocal  Resonance. — Finally,  speech 
sounds  may  be  diminished  in  intensity  by  the  same 
causes  which  diminish  the  tactile  fremitus ;  pleuritic 
effusions,  pleuritic  thickening,  separation  of  the  lung  by 
fluid  or  air,  and  by  over-distension  of  the  lung. 

NEW   OR  ADVENTITIOUS  SOUNDS. 

These  sounds  are  not  a  modification  of  preexisting 
sounds,  but  something  altogether  new  or  additional. 
They  include  rales,  or  rhonchi,  the  friction  sound, 
and  metallic  tinkling. 

Rales  are  new  sounds  produced  in  the  trachea,  bron- 
chial tubes,  or  in  cavities,  concurrent  with  the  movement 


NEW  OR  ADVENTITIOUS  SOUNDS.  79 

of  air  inward  or  outward  in  the  act  of  breathing.  They 
are  the  direct  result  of  some  partial  obstruction  to  the 
onward  movement  of  the  air,  for  the  most  part  within 
the  tube,  but  the  narrowing  may  also  be  the  result  of 
extra -tubal  pressure.  They  are  divided  into  moist  or 
dry  rales,  according  as  the  obstructing  substance  is  liquid 
or  the  reverse.  Both  are  influenced  by  coughing  and 
may  often  be  completely  removed,  for  the  time  being, 
by  this  act.  When  not  thus  influenced  by  coughing 
they  are  probably  due  to  pressure  from  without. 

Dry  Rales  are  sounds  engendered  in  the  air  of  the 
air  passages  by  any  causes  which  narrow  their  lumen. 
These  are  commonly  adherent  mucus  or  the  swollen 
mucous  membrane  of  the  bronchi.  Sounds  produced 
in  the  tubes  of  large  lumen,  hke  the  trachea,  are  musical, 
low  pitched,  and  are  called  sonorous  rales.  Those 
produced  in  the  small  tubes  are  high  pitched  and  hissing, 
and  therefore  cafled  sibilant  rales. 

Moist  rales  are  caused  by  the  passage  of  air  through 
liquid,  which  may  be  blood,  mucus,  or  seium.  They 
are  therefore  of  the  nature  of  bubbling  sounds  and  are 
spoken  of  as  large  and  small  bubbhng  sounds,  according 
as  the  bubbles  are  large  or  small,  and  as  large  bubbles 
can  only  form  in  tubes  of  large  size  or  cavities,  they 
indicate  these  conditions,  while  the  small  rales  indicate 
smaller  tubes.  Moist  rales,  except  the  crepitant,  are 
heard  in  inspiration  or  expiration,  or  both.  The  bub- 
bhng sounds  are  further  subdivided,  according  to  size, 
into  gurgling,  mucous,  submucous,  subcrepitant,  and 
crepitant  rales,  and  crackling. 


8o  PHYSICAL    DLA.GNOSIS. 

Gurgling  is  a  term  applied  to  the  largest  bubbling 
sounds,  and  is  produced  in  cavities  containing  fluid.  It 
is  also  known  as  the  cavernous  rale,  and  has  sometimes  a 
metallic  character  when  it  becomes  associated  with  the 
other  metallic  physical  signs  already  mentioned  as 
characteristic  of  a  cavity  with  firm  walls. 

The  mucous  rale  is  a  bubbling  sound  smaller  than 
the  cavernous,  but  still  of  large  size,  produced  in  the 
trachea  and  larger  bronchi.  The  death-rattle  is  a 
tracheal  mucous  rale.  The  submucous  rale  is  a 
smaller  bubbling  sound  produced  in  tubes  of  smaller 
size  and  the  subcrepitant  in  still  smaller.  The 
crepitant  rale  is  formed  in  tubes  of  smallest  size  and 
in  the  air  vesicles.  It  may  be  a  true  bubbhng  sound,  or 
it  may  be  due  to  the  separation  of  agglutinated  air  vesi- 
cles by  entering  air.  From  its  extreme  importance  in 
the  diagnosis  of  pneumonia,  although  it  occurs  also  in 
oedema  and  collapse  of  the  lungs,  it  requires  some  further 
illustration.  It  is  aptly  compared  to  the  crackling  pro- 
duced by  throwing  salt  on  the  fire,  or  rolling  the  hair 
between  the  fingers  alongside  of  the  ear ;  also  to  the 
noise  made  by  separating  near  the  ear  the  moistened 
thumb  and  index  finger.  The  f^rst  appears  to  me  the 
best  imitation.  It  is  heard  only  in  inspiration  and  is 
thus  distinguished  from  the  subcrepitant  rale,  which  is 
heard  in  expiration  as  well.  It  is  sometimes  heard 
throughout  the  whole  of  the  inspiratory  act,  more  fre- 
quently only  toward  the  end  of  it. 

Crackling  literally  means   the  same  as  crepitation, 
and,  in  fact,  the  mechanism  of  the  two  signs  is  nearly 


NEW   OR   ADVENTITIOUS   SOUNDS.  «I 

the  same.  Both  are  inspiratory  sounds,  and  both  may 
be  small  bubbles.  The  main  difference  is  really  in  the 
number  of  crackles  which  go  to  make  up  the  rale,  the 
crepitant  consisting  of  several  of  these,  while  the  crack- 
ling consists  of  but  one,  two,  or  three.  "  Crackling  " 
is  heard  at  the  apices  of  the  lungs,  and  the  crepitant 
rale  for  the  most  part  at  the  base.  The  interpretation 
of  crackling  is  almost  invariably  tubercular  consumption, 
and  it  means  that  the  tubercle  is  beginning  to  break 
down.  Yet  we  may  have  pneumonia  of  the  apex. 
What  is  known  as  "  moist  crackling  "  is  a  little  larger 
rale  than  crackling,  a  pure  bubbling  sound  produced  in 
the  smallest  bronchial  tubes,  and  is  really  a  subcrepita- 
tion.     It  is  essentially  a  subcrepitant  rale. 

Friction  sound  is  a  noise  produced  by  the  rubbing 
of  two  slightly  roughened  serous  surfaces  upon  each 
other.  The  pulmonary  and  costal  pleurae  and  the 
cardiac  and  pericardiac  serous  membranes  move  over 
each  other  smoothly  and  noiselessly  in  health,  but  let 
them  be  roughened  in  any  way  by  an  inflammatory 
exudate,  an  eruption  of  the  tubercles,  or  other  morbid 
growth,  and  at  once  the  friction  sound  is  produced.  In 
its  simplest  and  most  frequent  form,  representing  the 
first  stage  of  pleurisy,  it  also  resembles  somewhat  the 
crepitant  rale  and  it  is  sometimes  not  easy  to  distinguish 
from  it.  In  addition,  however,  to  being  more  superficial 
in  situation,  the  friction  sound  is  not  influenced  by 
coughing,  while  the  crepitant  rale  is.  The  friction 
sound  is  heard  more  loudly  if  the  stethoscope  is  pressed 
closely  to   the  chest  wall  and  is   localized,    while    the 


82  PHYSICAL   DIAGNOSIS. 

crepitant  rale  is  heard  over  a  large  area  of  lung.  It 
is  also  often  a  to-and-fro  sound,  being  heard  with  ex- 
piration as  well  as  with  inspiration,  while  the  crepitant 
rale  is  confined  to  inspiration.  The  friction  sound  dis- 
appears with  pleuritic  or  pericardial  effusion,  to  return 
for  a  time  with  the  subsidence  of  the  effusion. 

In  addition  to  its  typical  crepitant  like  character,  as 
heard  in  pleurisy,  the  friction  sound  assumes  also  at 
times  greater  roughness,  which  is  more  conspicuous  in 
pericardial  friction.  Where  organization  has  taken 
place  in  an  exudate  there  is  sometimes  a  leather  like 
creaking  produced  under  the  same  circumstances  as  the 
friction  sound,  and  it  is  regarded  as  a  friction  sound. 
It  is  sometimes  so  loud  as  to  be  heard  by  the  patient 
himself,  and  may  also  be  recognized  by  palpation. 
Pleural  friction  may  be  found  anywhere  in  the  chest, 
but  is  more  frequent  in  a  circumscribed  area  in  one  side 
of  the  chest,  especially  below  the  nipple  toward  infra- 
axillar}'-  region  or  below  the  angle  of  the  scapula. 

Metallic  tinkling  is  the  last  of  the  adventitious 
sounds  to  be  considered.  It  is  another  one  of  the  am- 
phoric sounds,  requiring  a  space  with  firm,  tense  walls  as 
its  condition.  ,A  pneumothorax  will  furnish  such  con- 
dition, as  also  do  certain  pulmonan,'  cavities.  Under 
these  circumstances  a  drop  of  liquid  falling  into  such  a 
space  will  produce  metallic  tinkling.  This  sometimes 
happens  in  a  pneumothorax  when  a  drop  of  secretion 
will  sometimes  fall  from  a  bronchial  tube  into  a  cavity. 
Such  resonance  also  is  contributed  to  rales  in  a  bronchus 
communicating  with  a  pneumothorax  or  cavit}\ 


ACUTE    BRONCHITIS.  8^ 

Allied  to  the  metallic  tinkling  is  the  Hippocratic 
succussion  produced  in  pyopneumothorax,  and  very 
rarely  in  a  cavity  whea  the  patient  is  shaken. 


PHYSICAL    SIGNS    OF    ABNORMAL 

STATES  OR  DISEASES  OF 

THE   LUNGS. 

ACUTE   BRONCHITIS. 

Acute  bronchitis  of  the  larger  tubes  is  essen- 
tially a  symmetrical  disease,  the  bronchi  of  both  lungs 
being  generally  more  or  less  equally  invaded.  There 
may  be  absolutely  no  physical  signs ;  inspection,  palpa- 
tion, percussion,  and  auscultation  being  alike  negative. 
In  other  cases  inspection  may  discover  increased  fre- 
quency of  respiratory  movement,  and  possibly  increased 
frequency  in  the  cardiac  apex-beat  if  there  be  fever. 
Palpation  may  appreciate  a  rhonchal  fremitus  if  there  be 
sufficient  narrowing  of  the  breathing  tubes.  It  may  be 
found  anywhere  or  on  either  side  and  may  be  very  tran- 
sient. Percussion  continues  invariably  clear  so  long  as 
the  bronchitis  is  uncomplicated. 

Auscultation  furnishes  the  most  distinctive  and  con- 
stant physical  sign,  the  presence  of  dry  rales,  the  sonor- 
ous and  sibilant,  which  may  invade  either  or  both  lungs, 
and  may  also  be  transient.  To  these  may  be  added 
harshness  of  breath  sounds.  In  the  resolution  of  bron- 
chitis, bubbling  rales  may  substitute  the  sonorous  and 
sibilant,  in  consequence  of  the  presence  of  liquid  secre- 
tion. 


84  PHYSICAL   DIAGNOSIS. 

Other  symptoms  are  pain  or  a  sense  of  oppression 
behind  the  sternum,  some  shortness  of  breath,  and  an- 
noying cough. 

Capillary  bronchitis,  catarrhal  or  broncho- 
pneumonia, involves  the  finer  and  finest  tubules  and 
adjacent  air  vesicles,  into  whch  it  generally  extends 
from  the  larger  bronchi.  The  frequent  breathing  is 
more  evident  and  constant ;  so  is  the  frequent  heart  beat 
with  fever.  Percussion  elicits  circumscribed  areas  of 
dulness.  Auscultation  recognizes  first  the  signs  of  an 
ordinary  acute  bronchitis,  followed  by  more  or  less  dis- 
tinct bronchial  breathing,  very  soon  by  small  bubbling 
rales,  subcrepitant  and  crepitant,  but  dry  rales  are  often 
absent  at  the  outset.  These  signs  are  most  frequent  in 
ttie  bases  of  the  lungs  posteriorly,  but  may  be  found 
anywhere  all  over. 

CHRONIC  BRONCHITIS. 

Physical  signs  attend  chronic  bronchitis  more  con- 
stantly than  acute,  yet  they  afford  no  unchanging  pic- 
ture. To  inspection  there  is  often  nothing  apparent, 
except  the  corresponding  motion  of  more  frequent 
breathing.  Even  this  is  sometimes  absent.  To  palpa- 
tion there  may  be  rhonchus  with  normal  tactile  fremitus, 
unchanged  or  slightly  increased  or  as  much  dimin- 
ished. To  percussiofi  there  may  be  no  change  or,  un- 
less in  the  vicinity  of  a  superficial  dilated  bronchus 
filled  with  secretion,  where  there  may  be  impairment  of 


EMPHYSEMA    OF    THE    LUNGS.  85 

resonance.  If  such  a  dilated  bronchus  be  emptied  of 
its  contents  by  expectoration,  the  percussion  signs  of  a 
cavity  may  be  present,  but  in  the  middle  or  lower  part 
of  a  lung  instead  of  the  apex.  Vesiculot5'mpanitic  or 
even  tympanitic  resonance  may  be  present  from  relaxa- 
tion of  lung  tissue,  especially  in  the  lower  posterior  part 
of  the  lungs. 

Auscultation  may  also  be  negative,  but  much  more 
frequently  recognizes  an  alternation  or  combination  of 
harsh  and  feeble  breathing,  sonorous  and  sibilant  rales, 
with  moist  rales  of  all  sizes,  variously  modified  by  dif- 
ferent distances  from  the  ear  and  varying  consistence  of 
the  secretion. 

Other  symptoms  are  cough  and  expectoration, 
usually  copious,  of  muco-purulent  sputum,  little  or  no 
pain  but  marked  shortness  of  breath. 

If  the  frequently  associated  complication  of  emphy- 
sema of  the  lungs  is  present,  the  signs  and  symptoms  of 
that  condition  are  superadded  as  detailed  below. 


EMPHYSEMA   OF  THE   LUNGS. 

This  condition,  an  over-distension  and  destruction  of 
air  vesicles  with  a  like  destruction  of  their  covering  of 
capillaries,  is  most  frequently  the  result  of  bronchitis  and 
a  complication  of  it.  It  may  also  be  produced  from 
forced  straining  efforts,  as  in  heavy  lifting  or  carrying 
heavy  loads.  It  also  commonly  affects  both  lungs  at 
the  same  time,  but  involves  different  lungs  and  different 
parts  of  the  same  lung  unequally. 


86 


PHYSICAL   DIAGNOSIS. 


The  physical  signs  are  more  or  less  distinctive. 
Inspection  discovers  a  rounded  chest  anteriorly  and  pos- 
teriorly, with  increased  circumference  and  wide  inter- 
costal spaces,  the  highest  degree  of  which  is  known  as 
the  "  barrel-shaped  chest  "  (Fig.  i8).  But  the  emphy- 
sema may  be  so  circumscribed  as  to  produce  local 
bulgings,  by  preference  in  the  upper  lobe  of  the  right 


Fig.  i8. — Bilateral  Enlargement  in  Emphysema  — {After  Gee.) 


and  lower  lobe  of  the  left  lung.  The  excursion  of 
expansion  of  the  chest-walls  is  diminished,  while  the 
scaleni  and  sterno-cleido-mastoid  muscles  stand  out  dis- 
tinctly. The  rate  of  the  movements  is  increased.  The 
apex  of  the  heart  is  displaced  downward  and  to  the 
right,  but  it  is  often  difficult  to  find,  because  covered 


EMPHYSEMA    OF    THE    LUNGS.  87 

up  by  the  enlarged  lung.  To  palpation  vocal  fremitus 
is  diminished,  while  the  natural  resiliency  of  the  chest- 
walls  is  substituted  by  increased  resistance. 

Pe7'cussio7i  recognizes  resonance  exaggerated  in  vari- 
ous degrees,  sometimes  amounting  almost  to  tympany, 
the  vesiculotympany  of  Flint.  The  cardiac  dulness  is 
extended  to  the  right  and  downward,  partly  from  dis- 
placement by  the  distended  lungs  and  partly  from 
hypertrophy  of  the  right  ventricle.  At  the  same  time 
the  cardiac  area  is  more  thoroughly  covered  by  the 
lungs,  and  pretty  strong  percussion  is  often  necessary  to 
bring  it  out.  The  hepatic  area  of  dulness  is  also  lowered 
by  reason  of  the  encroachment  of  the  lungs,  and  often 
diminished  from  the  same  cause. 

The  distinctive  auscultatory  sign  of  the  emphysema- 
tous area  is  the  feeble  inspiratory  murmur  due  to  the 
fact  that  the  air  vesicles  are  already  distended  with  air, 
and  current  conduction  is  impaired.  The  prolonged 
expiratory  murmur  is  the  result  of  the  lost  elasticity  of 
the  air  vesicles,  in  consequence  of  which  they  recoil  but 
slowly  on  their  contents.  Vocal  resonance  is  diminished 
because  of  the  diminished  motion  in  the  air  columns. 
Crackling  is  sometimes  heard.  If  bronchitis  be  present 
its  sounds  are  associated  and  often  obscure  all  else.  The 
pulmonary  second  sound  at  the  second  left  interspace  is 
accentuated  on  account  of  the  hypertrophy  of  the  right 
ventricle,  but  the  heart  sounds  are  usually  obscured  by 
the  extra  covering  of  the  lung.  With  dilation  of  the 
right  ventricle,  which  sooner  or  later  succeeds,  the 
increased  accentuation  disappears. 


80  PHYSICAL   DIAGNOSIS. 

Of  Other  symptoms  the  most  invariable  is  short- 
ness of  breath,  but  there  is  often  a  good  deal  of  cough. 

Interlobular  emphysema  is  a  condition  in  which 
the  connective  tissue  between  the  lobules  is  infiltrated 
with  air  as  the  result  of  rupture  of  air  vesicles  due  to 
violent  acts  of  coughing  or  to  wounds  of  the  lung. 

The  physical  signs,  except  to  inspection,  are  the  same 
as  those  of  vesicular  emphysema,  except  that  the  crack- 
ling sound  referred  to  is  more  common.  The  configu- 
ration of  the  chest  in  such  cases  is  not  usually  altered. 
Suddenness  of  onset  is  characteristic  of  this  form  of 
emphysema,  and  it  is  apt  to  be  associated  with  a  similar 
infiltration  of  the  tissues  of  the  neck,  which  gives  rise  to 
a  very  distinctive  crepitation  on  palpation. 

BRONCHIAL  OR  SPASMODIC  ASTHMA. 

The  physical  signs  of  this  peculiar  neurosis  reveal 
themselves  to  all  the  methods  of  physical  diagnosis  em- 
ployed. There  is  a  spasm  of  the  muscles  of  the  smaller 
bronchi.  Inspection  observes  the  most  labored  effort  in 
breathing,  while  the  chest  moves  but  slightly,  because 
the  lungs  cannot  be  inflated.  The  spaces  above  and 
below  the  clavicle  and  above  the  sternum,  the  inter- 
costal spaces,  and  the  pit  of  the  stomach,  are  drawn  in, 
for  the  same  cause, — that  is,  the  thoracic  cavity  not 
being  filled  from  within,  the  external  atmospheric  pres- 
sure forces  the  yielding  portions  inward. 

Rhonchal  fremitus  is  recognized  by  palpation,  while 
vocal  fremitus,  obscured  by  the  rhonchus,  is  otherwise 
diminished    by   a    frequently    associated    emphysema. 


PULMONARY   TUBERCULOSIS,  OR    CONSUMPTION.  89 

Percussion  is  negative  in  uncomplicated  asthma,  but  if 
asthma  is  associated  with  emphysema  it  may  produce 
abnormal  resonance. 

Auscultation  discovers  the  most  striking  and  easiest 
recognized  of  the  physical  signs.  All  over  the  chest 
are  heard  sonorous  and  sibilant  rales,  inspiratory  and 
expiratory,  but  more  commonly  the  latter.  In  fact,  for 
the  most  part  they  do  not  require  the  ear  to  be  placed 
close  to  the  chest  for  recognition.  The  vesicular  mur- 
mur, on  the  other  hand,  is  inaudible. 

It  is  to  be  remembered  that  chronic  bronchitis,  em- 
physema, and  asthma  may  also  complicate  each  other, 
and  render  correspondingly  complex  the  physical  signs. 

Other  symptoms  include  little  else  than  the  labored 
breathing  until  the  spasm  breaks  up  and  secretion  is 
established,  when  there  is  cough  and  scanty  sputum 
containing  small  lumps  in  which  Curschmann's  spirals 
and  Charcot-Leyden  crystals  are  found. 

PULMONARY  TUBERCULOSIS,  OR 
CONSUMPTION. 

Accepting  the  modern  doctrine  that  all  phthisis  is 
tubercular,  there  are  three  ways  in  which  it  invades  the 
lungs  : 

1.  As  catarrhal  or  bronchopneumatic  phthisis. 

2.  As  fibroid  phthisis. 

3.  As  miliary  tuberculosis  of  the  lungs. 
Catarrhal  Phthisis. —  This,  the  most  common  form 

of  consumption,  presents  two  varieties,  differing  mainly 
in    the    rapidity    of    their   course, — whence    acute  and 


90  PHYSICAL   DL4GN0SIS 

chronic  phthisis.  The  former  is  also  known  diS,  phthisis 
florida  or  galloping  consumption.  Perhaps  there  should 
be  added,  as  a  distinctive  feature  of  the  latter,  the  dif- 
fuseness  as  well  as  the  rapidity  of  the  process. 

Catarrhal  phthisis  resolves  itself,  with  more  or  less 
definiteness,  into  three  separate  stages,  of  which  the 
physical  signs,  commonly  sought  at  the  apices  of  the 
lungs,  are  also  more  or  less  distinctive  : 

1.  The  incipient  stage,  or  beginning  deposit* 

2.  Stage  of  complete  consolidation. 

3.  Stage  of  softening  and  cavity  formation. 

I.  Inspection,  in  the  incipient  stage,  is  as  often  negative 
as  not.  A  slight  impairment  of  motion  in  the  infra- 
clavicular space  may  be  present,  and  more  rarely  a  slight 
flattening  of  the  same  region.  The  clavicle  becomes 
correspondingly  conspicuous.  The  body  may  continue 
well  nourished  or  slightly  emaciated,  or  the  heart  beat 
in  the  normal  position  may  be  somewhat  accelerated, 
while  the  respirations  are  likely  to  be  more  frequent  than 
in  health. 

Palpation  recognizes  increased  vocal  fremitus  in  the 
same  situation,  although  this  may  not  always  be  notice- 
able in  the  first  stage,  while  the  physiological  difference 
in  favor  of  the  right  side  is  to  be  remembered.  Percus- 
sion in  this  stage  gives  slightly  higher  pitch  and  impair- 

*  This  subdivision  does  not  seem  to  me  as  satisfactory  nor  based 
on  as  well-defined  clinical  features  as  another  which  makes  the 
first  stage  that  of  cojtsolidation  ;  the  secoiid that  of  softe7ii7ig ;  third, 
tliat  of  cavity  formation  ;  but  for  the  sake  of  uniformity  with  other 
writers  I  retain  it  for  the  present. 


PULMONARY   TUBERCULOSIS,  OR    CONSUMPTION.  91 

ment  of  resonance,  which  may  be  noted  above,  on,  or 
below  the  clavicle.  Dulness  may  sometimes  be  brought 
out  by  directing  the  patient  to  hold  his  mouth  open 
during  percussion,  or  to  hold  his  breath  at  expiration. 

To  auscultation  above  or  below  the  clavicle,  we  have 
the  first  evidence  of  abnormality  in  a  prolongation  of 
the  expiratory  murmur  and  harshness  in  the  inspira- 
tory sound — the  bronchovesicular  breathing  described. 
Theoretically,  this  should  be  preceded  by  a  diminished 
intensity  in  the  inspiratory  sound,  owing  to  the  inter- 
ference of  the  newly  deposited  tubercles  with  the  con- 
duction of  sound  into  the  air  vesicles,  but  practically 
this  is  scarcely  encountered,  and  if  encountered,  is  of 
such  indistinctive  significance  as  to  be  of  little  value. 

Increased  vocal  resonance  is  a  constant  accompani- 
ment of  these  modifications  in  the  normal  breathing 
sounds,  but  it,  as  well  as  the  vocal  fremitus,  may  be 
masked  by  a  pleuritic  thickening,  and  the  physiological 
difference  so  often  referred  to  must  be  remembered. 
Da  Costa  also  calls  attention  to  the  fact  that  in  a  certain 
number  of  cases,  at  this  stage,  there  is  a  blowing  sound 
in  the  subclavian  or  pulmonary  artery,  and  that  a  mur- 
mur is  sometimes  present  in  the  subclavian  or  pulmonary 
artery  before  any  other  physical  sign  is  present.  There 
are  frequently  concurrent  with  these  signs  those  of  a 
bronchitis  more  or  less  acute. 

2.  In  the  second  stage  the  changes  discoverable  by 
inspection  are  more  easily  recognized.  There  is  evident 
loss  of  flesh,  depression  of  surface,  and  impaired  range 
of  respiratory  movement  on   the    side   affected.     The 


92  PHYSICAL   DIAGNOSIS. 

hectic  flush  is  intermittingly  present.  Palpation  may 
also  discover  an  increased  warmth  of  skin.  The 
increased  vocal  fremitus  should  be  plainly  recognized 
unless  obscured  by  a  thickened  pleural  membrane.  Dul- 
ness  on  peraission  is  positive. 

To  aiisctdtatioji  there  is  increased  vocal  resonance. 
The  bronchial  factor  in  the  breathing  now  becomes 
conspicuous,  showing  itself  by  the  harshness  and  relative 
shortening  of  the  inspiratory  element,  with  the  decid- 
edly rough  and  blowing  expiration ;  also  a  gradual 
diminution  of  the  vesicular  factor,  until  the  latter  dis- 
appears entirely,  when  we  have  the  typical  bronchial 
breathing  of  extended  areas  of  tubercular  mfiltration. 
This  sign  will  now  be  found  in  the  supraspinous  fossa 
as  well.  The  high  degree  of  vocal  resonance,  known  as 
bronchophony,  is  also  superadded  as  a  valuable  confirma- 
tion of  the  presence  of  complete  consolidation.  The 
auscultation  signs  of  a  concurrent  bronchitis  may  also  be 
present  in  this  and  the  next  stage.  The  heart  sounds 
are  sometimes  conducted  with  great  intensity  by  an 
adjacent  consolidated  area. 

3.  In  the  third  stage  the  information  furnished  by  in- 
spection is  still  more  decided.  Emaciation  is  extreme, 
and  breathing  and  the  pulse  are  rapid,  the  face  often 
flushed.  There  is  flattening  over  the  affected  area,  and 
the  excursion  of  respiratory  movement  is  still  more 
limited.  In  this  stage  the  superficial  veins  over  the  in- 
volved area  may  be  prominent,  partly  from  emaciation 
and  partly  from  obstructed  circulation. 

To  palpation  the  vocal  fremitus  is  still  more  marked. 


PULMONARY   TUBERCULOSIS,  OR   CONSUMPTION.  93 

and  even  remains  distinct  over  cavities,  because  of  the 
consolidation  around  them,  unless  there  be  some  ob- 
struction to  the  entrance  of  air  in  the  bronchus  leading 
to  the  involved  area.  Rhonchal  fremitus  may  be  added 
if  adventitious  sounds  are  present.  The  skin  is  hot  and 
dry,  unless  succeeding  one  of  the  sweats  which  charac- 
terize this  stage,  when  it  may  be  moist  and  clammy. 

Dulness  on  percussion  is  always  to  be  found  in  the 
third  stage,  but  to  it  is  constantly  added  some  one  of 
the  varieties  of  tympanitic  note  referred  to,  viz.,  pure 
tympany,  the  "  cracked-pot  "  sound,  or  amphoric  reso- 
nance, due  to  cavities.  These  require  sufficient  size 
and  superficial  situation  on  the  part  of  the  cavity,  and 
the  other  conditions  described  on  pages  55,  56,  57,  and 
58.  On  the  other  hand,  resonance  may  even  be  normal 
over  a  cavity  some  distance  from  the  surface,  especially 
if  the  percussion  be  lightly  made. 

Auscultation  in  this  stage  may  continue  to  recognize 
the  bronchial  breathing  of  the  second,  but  to  it  may  be 
superadded  the  distinctive  signs  of  a  cavity,  which  may 
also  supplant  those  of  the  bronchial  breathing.  These 
signs  are  cavernous  breathing,  cavernous  voice,  or  pec- 
toriloquy, either  when  whispering  or  speaking  with  the 
ordinary  voice,  amphoric  breathing,  and  amphoric  voice, 
the  full  import  and  conditions  of  all  of  which  have  been 
described.  To  these  are  often  added  the  large  bubbling 
sounds  known  as  gurgling,  caused  by  the  air  bubbling 
through  the  fluid  in  a  cavity.  Metallic  tinkling  may  be 
added  to  these  phenomena,  caused  by  the  bursting  of 
bubbles  in  a  cavity  with  the  amphoric  conditions. 


94  PHYSICAL    DL4GN0SIS. 

The  heart  sounds  are  often  heard  with  great  intensity 

and  even  with  amphoiic  note  over  neighboring  cavities. 

Fibroid  Phthisis,  or  Cirrhosis  of  the  Lung. — 

Fibroid  phthisis  does  not  admit  of  the  same  sharp  divi- 
sion into  stages  which  characterizes  catarrhal  phthisis. 
Frequently  traceable  in  its  initial  symptoms  to  the  inha- 
lation of  irritating  substances,  and  much  more  chronic 
in  its  course  even  than  the  chronic  form  of  catarrhal 
phthisis,  the  general  clinical  history  is  of  great  value  in 
distinguishing  it  from  the  latter.  It  is  constantly  asso- 
ciated in  its  beginning  with  pleurisy,  and  it  may  be  a 
sequel  of  it. 

The  degree  of  retraction  as  noted  by  inspection  is 
greater  and  more  easily  recognized,  and  not  confined  to 
the  apices  of  the  lungs.  The  heart  is  frequently  dislo- 
cated and  its  apex  correspondingly  displaced,  sometimes 
to  an  extreme  degree.  If  on  the  left  side,  owing  to  the 
retraction  of  the  lung,  there  is  sometimes  noted  a  dis- 
tinct cardiac  pulsation  in  the  3d,  4th,  and  5  th  inter- 
spaces. The  intercostal  spaces  are  often  narrowed  and 
the  diaphragm  may  be  drawn  up.  The  modifications  of 
vocal  fremitus  as  revealed  to  palpation  are  not  nearly  as 
constant,  being  masked  by  the  retraction  and  pleuritic 
comphcations,  and  may  be  absent.  There  is  usually 
little  or  no  elevation  of  temperature. 

Peraission  is  more  constant  in  its  results,  there  being 
marked  dulness  and  a  wooden-like  resistance.  There  is 
sometimes  hypertrophy  of  the  right  ventricle  due  to  the 
extra  effort  of  the  right  heart  to  propel  the  blood 
through  the  obstructed  lung  areas.     Auscultation  most 


PULMONARY   TUBERCULOSIS,  OR   COiSTSUMPTION.  9  5 

frequently  notes  bronchial  breathing  and  exaggerated 
voice,  but  both  of  these  may  be  lessened  in  intensity  by 
thickened  pleurae. 

A  dilated  bronchus  is  a  frequent  result,  furnishing  the 
signs  of  a  cavity,  which  may  be  in  the  middle  or  even 
at  the  base  of  the  lung,  and  furnishes  a  copious  expec- 
toration characterized  by  a  peculiar  fetor,  in  which  the 
microscope  sometimes  discovers  fat-crystals. 

To  the  signs  of  the  fibroid  state  in  one  part  of  a  lung 
are  frequently  added  those  of  emphysema  in  the  re- 
mainder or  in  the  other  lung,  or  there  may  be  a  similar 
involvement  of  that  lung. 

The  rarity  with  which  the  bacillus  tuberculosis  is 
found  in  the  sputum  in  this  condition  is  not  regarded  as 
sufficient  evidence  to  exclude  it  from  the  category  of 
tubercular  diseases. 

Acute  miliary  tuberculosis  is  not  accompanied  by 
any  distinctive  physical  signs,  and  the  diagnosis  is  made 
from  the  clinical  and  hereditary  history  rather  than 
from  such  signs.  The  temperature  is  high  and  exceed- 
ingly fluctuating.  A  tympanitic  or  hyperresonant  per- 
cussion  note  is  sometimes  present  throughout  the  lung 
in  disseminated  miliary  tuberculosis  due  to  the  relaxed 
state  of  the  air  vesicles  which  such  an  infiltration  favors. 

Not  every  case  of  tuberculosis  of  the  lungs  begins  in 
the  apex,  nor  even  when  it  does  thus  begin  are  the 
physical  signs  always  first  discovered  anteriorly.  Ex- 
amination of  every  case  should  therefore  include  the 
posterior  portion  of  the  lung,  and  especially  the  supra- 


96  PHYSICAL   DIAGNOSIS. 

spinous  fossae.  Tuberculosis  not  ven'  rarety  succeeds 
upon  a  pneumonia  as  well  as  upon  a  pleuris}',  and  espe- 
cially a  catarrhal  pneumonia,  when  the  signs  first  make 
their  appearance  in  the  area  which  has  been  made  vul- 
nerable by  the  previous  state.  Indeed,  many  cases  sup- 
posed from  the  physical  signs  to  be  pneumonia  are 
tubercular  from  the  beginning. 


PNEUMONIA. 

Acute  croupous  or  lobar  pneumonia,  more 
common  in  the  right  lower  lobe,  presents  three  easily 
separated  sets  of  physical  signs  corresponding  to  as 
many  stages  in  the  morbid  process  itself. 

The  FIRST,  or  stage  of  congestion,  jn  which  the  air 
vesicles  are  still  open,  is  of  short  duration,  terminating 
within,  the  first  twenty-four  hours,  and  may  therefore  be 
overlooked.  Inspection  notes  the  face  flushed,  increased 
frequency  of  respiration,  with  restricted  movement  upon 
the  involved  side  and  exaggerated  motion  on  the  sound 
side.  The  patient  lies  by  preference  on  the  affected 
side  because  of  the  greater  comfort  it  gives  him.  This 
posture  not  only  diminishes  the  pain  by  hindering  the 
motion  of  the  affected  side,  but  also  lessens  the  dyspnoea 
by  permitting  unrestrained  expansion  of  the  other  side 
which  is  doing  the  work. 

Palpation  at  first  may  even  find  vocal  fremitus  dimin- 
ished on  account  of  the  relaxation  of  the  air  vesicles, 
but  vocal  fremitus  becomes  decidedly  increased  as  the 
air  vesicles  fill  up.     The  skin  is  hot  and  the  pulse  is  fre- 


PNEUMONIA.  97 

quent.  Percussion  obtains  but  slight  if  any  impairment 
of  resonance.  In  fact,  tympany  or  the  vesiculotympany 
of  Flint  is  frequently  present  in  this  stage  as  the  result 
of  the  relaxation  of  the  partially  filled  air  vesicles, 
giving  resonance  by  immediate  relaxation.      (See  p.  54.) 

Auscultation  in  the  very  earliest  stage  may  find  the 
vesicular  murmur  feeble,  but  very  soon  is  heard  the  dis- 
tinctive physical  sign  of  pneumonia,  the  crepitant  rale 
at  the  end  of  inspiration,  or  if  there  be  coincident 
pleurisy — pleuropneumoiiia — the  closely  simulating  fric- 
tion sound  may  be  added.  Morison  *  calls  attention 
to  a  jerky  expiration  over  a  limited  area  as  the  first 
physical  sign,  heard  soon  if  not  immediately  after  the 
rigor,  before  dulness  or  crepitation  appears.  The  sign 
is  said  to  be  more  distinct  in  children,  but  has  been 
noted  in  adults.  Over  the  normal  part  of  the  lung  there 
is  exaggerated  vesicular  breathing. 

But  all  of  these  physical  signs,  even  if  carefully  sought 
for,  may  be  wanting  if  the  pneumonia  is  deep-seated,  as 
is  not  infrequently  the  case.  They  appear  as  the  surface 
is  reached,  or  they  may  not  be  recognized  at  all  if  it 
remains  central. 

The    SECOND    STAGE,-  Or    STAGE    OF    RED     HEPATIZATION, 

or  solidification,  lasting  four  or  five  days,  furnishes  un- 
mistakable signs.  All  the  signs  pneumonia  reveals  to 
inspection  in  the  first  stage  are  intensified  in  the  second, 
and   the  breathing  is  markedly  abdominal.     To  palpa- 

*  Medical  News,  Dec.  16,  1893,  P-  683,  from  Lancet,  No.  3656, 
p.  746.      , 


98  PHYSICAL   DIAGNOSIS. 

tion,  vocal  fremitus  is  now  intense,  the  skin  is  hot  and 
dry,  and  the  pulse  continues  frequent. 

Percussion  gives  absolute  flatness  over  the  solidified 
area,  with  high  pitch  and  short  duration,  except  in 
those  very  rare  instances  alluded  to  on  p.  58,  where  the 
extreme  consolidation  throws  the  column  of  air  in  the 
trachea  and  bronchi  into  vibration,  producing  tympany. 
This  explanation  is  perhaps  the  only  one  when  it  occurs 
in  the  upper  lobe.  In  a  lower  lobe,  tympany  may  result 
in  the  same  way,  from  the  proximity  of  a  dilated  stomach. 
Over  the  adjacent  normal  areas,  also,  resonance  is  ex- 
aggerated in  consequence  of  the  supplemental  action  of 
these  parts.  Here  there  may  even  be  tympany  or  vesi- 
culotympany  due  to  the  relaxation  of  the  adjacent  air 
vesicles,  an  instance  of  resonance  by  mediate  relaxation. 
Even  cracked-pot  sound  may  be  produced  by  percussion 
over  the  solidified  lung  as  the  result  of  the  sudden  ex- 
pulsion of  -air  from 'a  large  bronchus  leading  to  the 
solidified  area. 

Ausadtation  discerns  high-pitched  bronchial  breath- 
ing over  the  solidified  lung.  Indeed,  these  are  the  cir- 
cumstances which  give  the  typical  bronchial  or  tubal 
breathing.  The  air  vesicles  are  obliterated,  and  the 
resulting  excellent  conducting  medium  brings  the 
tracheobronchial  blowing  to  the  ear.  The  ausculted 
voice  gives  us  typical  bronchophony  and  occasionally 
even  pectoriloquy,  as  well  as  whispering  bronchophony 
and  pectoriloquy.  The  heart  sounds  are  also  heard  with 
great  distinctness  over  the  consolidated  lung,  owing  to 
the  improved  conduction,  while  the  sounds  of  a  cpr\cur- 


PNEUMONIA.  99 

rent  bronchitis  are  similarly  intensified.  A  lingering 
crepitant  rale  may  also  be  heard. 

The     THIRD     STAGE,     Or    STAGE     OF    GRAY    HEPATIZATION 

or  resolution,  occupies  six  to  ten  days.  It  repeats  largely, 
to  inspection,  palpation,  and  auscultation,  the  phenomena 
of  the  first.  Resonance  continues  impaired  for  some 
time.  The  normal  manner  of  breathing  gradually 
returns,  the  temperature  of  the  skin  is  noticeably  less, 
the  crepitant  rale  returns,  technically  known  as  the 
"  crepitans  redux,"  and  is  finally  replaced  by  the  normal 
vesicular  breathing  sound,  by  which  time  the  dulness  has 
disappeared. 

Croupous  pneumonia  may  rarely  terminate  in  abscess 
or  gangrene,  when  the  signs  of  the  second  stage  con- 
tinue, the  temperature  does  not  fall,  in  a  word,  the  crisis 
does  not  occur.  The  signs  of  a  cavity  which  might 
naturally  be  expected  are  rarely  present,  and  it  is  rather 
the  general  symptoms,  the  failure  to  recover,  the  con- 
tinued high  temperature,  the  expectoration  of  pus,  and, 
in  the  case  of  gangrene,  the  intensely  disagreeable  odor, 
that  informs  us  of  the  issue.  These  issues  probably 
represent  on  a  large  scale  what  takes  place  in  every  in- 
stance in  minute  areas  in  the  third  stage  of  all  pneumo- 
nias which  terminate  favorably.  The  occasional  termi- 
nation in  tubercular  phthisis  exhibits  a  similar  arrest  of 
the  resolving  process  in  the  second  stage,  and  the  phe- 
nomena of  the  catarrhal  or  fibroid  phthisis  supervene. 

The  obscuring  effect  of  a  thickened  pleura  upon  all 
of  these  signs  is  to  be  remembered,  and  too  much  stress 
cannot  be  laid  upon  the  fact  that  we  may  have  a  central 


lOO  PHYSICAL   DL4GN0SIS. 

deep-seated  pneumonia  which  may  give  no  physical 
signs,  also  that  in  old  persons  the  physical  signs  of  a 
pneumonia  are  very  apt  to  be  delayed  from  one  to  three 
days. 

Other  symptoms  are  sudden  onset  with  chills, 
dull  pain,  cough  with  rusty,  rather  scanty  tenacious 
expectoration,  flushed  cheeks,  frequent  breathing,  and 
high  continuous  fever.  The  sputum  contains  pneu- 
mococci. 

Catarrhal  or  Lobular  Pneumonia  or  Broncho- 
pneumonia.— The  phj^sical  signs  of  this  form  of  pneu- 
monia are  not  nearly  so  distinctive  as  those  of  croupous. 
A  circumscribed  affection  involving  a  few  lobules,  the 
physical  signs  are  necessarily  more  obscure.  Occurring 
most  frequently  in  the  course  of  a  bronchitis  in  children 
and  in  old  persons,  as  well  as  de  novo  in  the  former,  the 
physician  should  be  on  the  watch  for  it  under  these  cir- 
cumstances. It  also  occurs  in  adults,  though  more 
rarely,  especially  in  those  suffering  from  tuberculosis,  as 
the  result  of  insufflation  of  broken-  down  tubercular 
matter,  which  produces  by  inoculation  and  irritation  a 
tubercular  bronchopneumonia.  When  superadded  to  a 
bronchitis  under  any  of  these  conditions,  there  ensue 
increase  of  fever,  embarrassed  breathing,  and  associated 
increased  inspiratory  effort.  Palpation  should  recognize 
increased  vocal  fremitus  if  the  area  involved  be  suffi- 
ciently large, /i?;r//j'j-/(9;;  should  reveal  dulness  and /I'w- 
panicity  of  adjacent  supplementally  acting  areas.  Aus- 
cultation will  also  discover  in  the  inflamed  area  the 
crepitant  rale,  the  bronchial  breathing,  increased  vocal 


PNEUMONIA.  lOI 

resonance,  and  bronchophony,  in  addition  to  the  physi- 
cal signs  of  the  concurrent  bronchitis. 

Embolic  Pneumonia  and  Hemorrhagic  In- 
farct.— Pulmonary  Apoplexy. — The  effect  of  the 
lodgment  of  an  embolus  from  any  source  in  a  branch  of 
the  pulmonary  artery  is  to  produce  an  extravasation  of 
blood  in  the  conical  area  formerly  supplied  by  the  vessel. 
Such  an  extravasation  is  called  a  hemorrhagic  infarct. 
It  is,  in  fact,  a  circumscribed  apoplexy,  but  the  term 
apoplexy  of  the  lung  is  better  retained  for  such  extrava- 
sations of  blood,  circumscribed  or  diffuse,  as  are  due  to 
rupture  of  branches  of  the  pulmonary  artery  from  other 
causes  than  embolism.  Such  is  over-distension  of 
blood-vessels  in  valvular  disease  of  the  heart,  disease  of 
the  blood-vessel  wall,  or  traumatism. 

Small  infarcts  of  the  lungs  may  give  rise  to  no  symp- 
toms whatever.  When  large  enough  they  cause  sudden 
pain  and  embarrassed  breathing,  rusty  expectoration, 
and  circumscribed  dulness,  all  of  which  increase  with 
the  size  of  the  infarcted  areas.  Palpatio7i  reveals 
increased  vocal  fremitus,  and  auscultation  crepitant  and 
subcrepitant  rales,  bronchial  breathing,  and  broncho- 
phony. These  are  the  signs  of  a  croupous  pneumonia, 
which  is  indeed  present,  the  consequence  of  the  infarct, 
which  acts  as  an  irritant.  The  circumscribed  area 
covered  by  these  signs  would  exclude  an  ordinary  croup- 
ous lobar  pneumonia,  while  the  absence  of  fever,  the 
suddenness  of  onset,  and  the  presence  of  cardiac  disease 
aid  in  the  diagnosis. 

.Similar  symptoms  may  be  caused  by  massive  hemor- 


I02  PHYSICAL    DLA. GNOSIS. 

rhage  into  the  lungs,  or  pulmonary  apoplexy,  caused  by 
the  rupture  of  a  large  branch  of  the  pulmonar}'^  artery, 
whose  wall  is  weakened  by  tuberculous  infiltration  or  the 
engorgement  due  to  vahnilar  heart  disease.  Such  a 
vessel  may  suffer  a  further  strain  in  consequence  of  some 
transitor}'  congestion,  and  rupture  occurs.  A  great  mass 
of  blood  is  poured  out,  which,  besides  entering  the 
bronchial  tubes  and  producing  haemoptysis  and  mucous 
rales,  also  infiltrates  the  lungs,  coagulates,  and  produces 
consolidation.  If  the  patient  lives,  the  blood  in  the 
bronchi  may  be  insufiiated  into  the  vessels  and  there  act 
as  an  irritant,  producing  intense  inflammaiion  followed 
by  gangrene  or  abscess. 

Pulmonary  cedema  furnishes  many  of  the  signs  of 
the  first  stage  of  croupous  pneumonia,  and  is  sometimes 
accompanied  by  a  frothy,  pinkish  expectoration ;  but 
the  absence  of  fever,  and  the  presence  of  dropsy  else- 
where, or  its  causes,  account  for  the  condition. 

Collapse  of  the  Lung. — In  the  course  of  a  capillary 
bronchitis  there  sometimes  occurs  a  collapse  of  a  portion 
of  the  lung,  owing  to  a  valvular  plugging  of  a  bronchus, 
as  the  result  of  which  air  may  pass  out  during  expiration 
but  cannot  enter  with  inspiration,  or  it  may  occur  as 
the  result  of  a  want  of  strength  to  fill  the  air  cells.  The 
area  of  collapse  often  corresponds  in  size  with  that  of 
lobular  pneumonia. 

When  such  collapse  occurs  there  is  sudden  difficult 
breathing  noticed  on  inspection,  hnt  palpation  gives  no 
information.  Percussion  reveals  dulness,  but  it  is  much 
less  marked  than   in  lobular  pneumonia,  while  ausculta- 


PLEURISY.  103 

Hon  finds  no  bronchial  breathing,  or  if  present  it  is  very 
feeble  ;  no  bronchophony,  but  rather  diminished  inten- 
sity of  breathing  sounds  and  diminished  voice.  Col- 
lapse of  the  lung  is  apt  to  be  symmetrical. 

Compressed  lung,  most  frequently  due  to  pleural 
effusion,  generally  furnishes  flattening,  increased  vocal 
fremitus,  impaired  resonance,  increased  vocal  resonance, 
and  bronchial  or  bronchovesicular  breathing. 

Cancer  of  the  lung  furnishes  signs  of  consolidation 
very  similar  to  those  of  the  second  stage  of  tubercular 
consumption.  Flattening,  increased  fremitus,  dulness, 
increased  vocal  resonance,  bronchial  breathing,  all  ex- 
cept elevation  of  temperature,  may  be  present,  and  it  is 
the  history  of  the  case  and  special  symptoms  that  de- 
termine the  diagnosis  rather  than  the  physical  signs. 
Plistory  of  heredity,  cancer  elsewhere,  cachexia,  more 
constant  and  severe  pain,  are  symptoms  of  importance 
In  the  diagnosis.  A  peculiar  currant-jelly-like  sputum 
is  much  mentioned  as  characteristic. 


PLEURISY. 

Acute  pleurisy  is  also  resolvable  into  three  stages, 
each  of  which  is  characterized  by  physical  signs  more  or 
less  distinctive.  They  include  a  dry  stage,  a  stage  of 
effusion,  and  a  stage  of  resolution  or  absorption. 

The  FIRST  or  dry  stage  is  characterized  anatomic- 
ally by  the  presence  of  the  so-called  lymph  or  exudate 
on  the  pleural  surfaces.  During  this  is  revealed  to  in- 
spection a  restrained  expansion  of  the  affected  side,  often 


I04  PHYSICAL   DIAGNOSIS. 

thrown  into  jerks  or  catches  because  of  the  pain  suffered 
in  a  continuous  inspiration.  The  expansion  on  the 
opposite  side,  on  the  other  hand,  is  full  and  unham- 
pered. The  patient  is  apt  to  lie  on  the  affected  side. 
Very  X2iie\y palpation  recognizes  a  fremitus  corresponding 
to  the  friction  of  the  two  pleural  surfaces.  I-ercussion 
in  this  stage  is  negative  as  to  modified  note,  but  often 
causes  decided  pain.  Auscultation  recognizes  the  fric- 
tion sound  already  described.  It  may  be  at  a  single 
spot  in  the  inframammary  or  infra-axillary  space,  and 
hence  be  overlooked.  At  other  times  it  may  be  noted 
over  a  considerable  area. 

The  inflammatory  process  may  stop  here  and  resolu- 
tion take  place,  or  it  may  continue  into  the  second  or 
STAGE  OF  EFFUSION.  The  signs  of  this  stage  vary  with 
the  amount  of  liquid  in  the  sac.  With  a  small  amount 
the  lungs  are  slightly  floated  up,  and  there  may  be  no 
signs  unless  there  be  a  vesiculotympany  above  the  line 
of  the  fluid,  a  Skodaic  resonance  by  mediate  relaxation 
of  the  air  vesicles. 

The  effusion,  however,  rarely  remains  so  trifling,  but 
commonly  rises  to  the  mid-chest.  In  the  upright  posi- 
tion of  the  patient,  inspection  discovers  in  a  spare  person 
shallowness  and  perhaps  obliteration  of  the  lower  inter- 
costal spaces.  The  motion  of  the  chest-wall  is  lessened 
both  in  the  vertical  and  transverse  directions. 

To  palpation  vocal  fremitus  is  diminished  over  the 
area  of  effusion,  but  may  be  increased  in  the  lung  above 
it.  To  percussion  there  is  absolute  flatness  over  the  area 
of  eft'usion,  but  the  line  of  demarcation   is  not  every- 


PLEURISY.  105 

where  at  the  same  level,  being  higher  behind  than  in 
front.  The  late  Dr.  Calvin  Ellis  first  called  attention  to 
an  S-like  curve  in  the  line  of  demarcation  which  is  said 
to  be  characteristic.  Very  important  in  the  diagnosis  is 
the  fact  that  the  fluid  changes  its  level,  and  with  it  the 
line  of  dulness,  when  the  position  of  the  patient  is 
changed.  There  is  also  an  abnormal  sense  of  resistance 
to  the  finger  in  percussing  over  the  area  of  effusion. 
Above  the  effusion,  especially  anteriorly,  there  is  again 
Skodaic  resonance  by  mediate  relaxation,  and  even 
sometimes  a  cracked-pot  sound.  Tympany  may  also  be 
present,  due  to  the  proximity  of  a  distended  stomach. 

To  auscultation,  the  breathing  sounds  are  inaudible 
or  very  feeble,  as  compared  to  the  corresponding  por- 
tion of  the  opposite  side,  but  vocal  resonance,  though 
diminished,  is  still  well  heard  where  the  collection  of 
fluid  is  moderate.  Above  the  line  of  dulness  there  is 
occasionally  a  friction  sound,  and  close  to  the  root  of 
the  lung  bronchial  breathing  may  be  heard.  This  is, 
however,  more  apt  to  be  the  case  when  the  effusion  is 
larger  and  the  lung  is  further  compressed.  Qilgophony 
is  also  sometimes  heard. 

When  the  effusion  is  larger,  filling  up  two-thirds  or 
three-fourths  of  the  pleural  sac,  the  effects  described  are 
increased,  while  new  ones  are  added.  Inspectio7i  notes 
that  respiratory  movement  is  still  more  hampered,  the 
intercostal  spaces  are  widened  and  even  bulging,  while 
fluctuation  may  sometimes  be  recognized  through  them. 
The  heart  is  displaced  by  the  accumulated  fluid,  and  if 
it  be  in  the  left  sac,  the  apex  is  often  found  far  over  to 


Io6  PH\-SiCAL    DIAGNOSIS. 

the  right  of  the  median  line,  and  if  on  the  right,  the 
apex  is  pushed  further  to  the  left.  Its  sounds  are  not, 
however,  altered  further  than  to  be  heard  more  intensely 
in  the  situation  where  the}'  are  not  usually  so  heard,  be- 
cause sound  is  transniitted  more  readily  through  a  single 
uniform  medium  than  through  two  or  more  of  different 
densities.  On  the  opposite  side  the  breathing  move- 
ments are  supplementally  increased.  There  is  complete 
absence  of  vocal  fremitus  on  the  affected  side. 

In  pleural  effusion  the  line  at  which  the  movement  in 
Litten's  sign,  or  the  diaphragm  phenomenon,  begins,  is 
lowered  from  the  6th  interspace,  while  if  the  effusion  is 
large  it  is  entirely  obliterated. 

Perctission  is  absolutely  flat  all  over  the  effusion,  and 
Skodaic  resonance  is  not  now  obtainable,  because  the 
lung  is  too  thoroughly  compressed  up  into  the  apex  of 
the  sac.  Resistance  to  pressure  is  marked.  On  ans- 
cultatio7i  bronchial  breathing  may  be  heard  at  the  upper 
part  of  the  lung  posteriorly,  because  the  large  tubes  are 
still  pervious  to  air,  and  the  compressed  lung  intensifies 
the  sound.  Sometimes  bronchial  breathing  is  heard  in 
more  peripheral  parts  of  the  chest,  probably  conducted 
hither  along  a  band  of  adhesion  or  along  a  rib.  Else- 
where there  is  absence  of  breath  sounds.  Vocal  reso- 
nance and  whispering  voice  are  alike  absent,  or  the 
former  is  ver}'  feeble.  Diminished  vocal  resonance  and 
diminished  tactile  fremitus  are  the  distinctive  featuj-es 
which  distinguish  a  bronchial  breathing  of  pleurisy  from 
that  of  pneumonia.  In  certain  situations,  too,  high  up, 
where  there  is  but  a  thin  film  between  the  chest-wall 


PLEURISY.  107 

and  the  lung,  there  may  be  oegophony,  but  this  is  more 
apt  to  be  present  as  the  fluid  is  being  absorbed. 

By  massive  effusion  on  the  right  side  the  hver  is  de- 
pressed. 

In  the  THIRD  STAGE,  if  resolution  takes  place  with  a 
gradual  retrocession  of  the  fluid  and  the  reexpansion  of 
the  lung,  we  have  a  return  to  normal  physical  signs. 
There  may  be,  too,  a  friction  redux.  A  considerable 
time  is,  however,  required  for  absorption,  and  it  is 
often  many  days  before  the  normal  breathing  sounds 
are  heard  with  their  usual  intensity  or  the  natural  fre- 
mitus is  felt.  Often  resolution  is  not  complete,  and 
there  then  remain  the  symptoms  and  sequelae  of 
chronic  pleurisy. 

Other  symptoms  of  acute  pleurisy  are  sharp  pain 
in  the  side,  short,  rapid  breathing,  and  suppressed,  dry 
cough. 

Chronic  Pleurisy. — Its  symptoms  and  sequelse  are 
not  uniform.  The  simplest  and  most  harmless  expres- 
sion is  a  thickened  pleiu-al  ?ne77ibraiie.  In  this  there  is 
no  adhesion  between  the  opposite  pleural  surfaces,  and 
the  motion  of  the  lung  is  not  interfered  with.  There 
is,  however,  a  general  interference  with  the  conduction 
of  sound,  and  all  the  normal  physical  signs — including 
vocal  fremitus,  vocal  resonance,  normal  percussion 
sounds,  and  normal  breathing  sounds — are  diminished  in 
intensity.  For  the  same  reason  many  abnormal  physical 
signs,  as  already  more  than  once  instanced,  are  also 
less  plainly  heard. 

The  serious  symptoms  of  chronic  pleurisy  are  more 


Io8  PHYSICAL   DIAGNOSIS. 

frequently  manifested  in  the  results  of  delayed  absorp- 
tion of  effusion,  and  in  a  change  of  its  character  from 
serous  to  purulent.  The  resulting  accumulation  of  fluid 
in  the  pleural  cavity  is  not  always  a  continuation  of 
acute  disease.  A  chronic  pleurisy  may  originate  de  nozw, 
and  often  without  the  consciousness  of  the  patient, 
although  a  careful  analysis  of  the  case  will  not  fail  to 
find  symptoms  of  ill  health  which  are  explained  by  the 
state  of  affairs  ultimately  found.  Such  pleurisies  are 
known  as  latent.  With  the  discovery  of  the  effusion, 
which  may  depend  more  or  less  on  the  acumen  of  the 
physician,  the  latency  disappears. 

Such  fluid  furnishes  the  physical  signs  detailed  on 
page  104  and  following  pages.  Its  further  effects  vary 
very  much  according  as  it  is  serum  or  pus.  In  either 
event  its  speedy  removal  is  desirable,  because  the  longer 
it  remains  compressing  the  lung,  the  longer  will  the 
latter  be  in  returning  to  its  natural  state.  Hence,  it  is 
better  done  by  aspiration  than  by  the  slower  method  of 
medication.  If  the  fluid  be  serous,  and  if  it  has  not 
been  too  long  retained,  the  lung  gradually  resumes  its 
normal  state,  and  a  thickened  pleura  is  all  that  remains, 
with  the  physical  signs  referred  to  as  associated  with  it. 
Not  infrequently,  however,  the  two  pleural  surfaces, 
costal  and  pulmonary,  remain  permanently  agglutin- 
ated, and  then,  although  the  lung  slowly  resumes  its 
natural  furiction,  there  still  remains  some  flattening  over 
the  lower  part  of  the  thorax,  while  the  signs  of  a  com- 
pressed lung  may  be  found  at  the  apex. 

If  the  liquid  be  pus,  we  have  an  empyema,  and  the 


PLEURISY,  109 

consequences  are  much  more  serious.  The  occurrence 
of  a  chill  and  continued  high  temperature  will  suggest 
a  purulent  collection.     BaccelH's  test  may  be  tried.  * 

Medical  treatment  almost  never  removes  an  empyema, 
and  aspiration  is  as  invariably  followed  by  reaccumu- 
lation.  Hence,  permanent  measures,  as  the  introduction 
of  a  drainage  tube  with  or  without  exsection  of  a  rib, 
must  be  used.  If  the  drainage  tube  be  inserted  early,  the 
lung  may  resume  its  natural  office,  and  there  may  be  no 
more  permanent  damage  than  the  agglutination  referred 
to,  and  subsequently  a  retracted  thorax.  More  fre- 
quently, however,  we  have  to  do  with  a  lung  partly 
bound  by  adhesions  into  its  new  and  unnatural  position, 
while  the  pleural  surface  may  be  looked  upon  as  an  ex- 
tensive ulcer.  The  restrained  lung  is  unable  to  expand 
to  refill  its  naural  space,  while  the  huge  ulcer  referred 
to  must  heal  slowly  with  a  resulting  cicatrix.  This  cica- 
trix has  the  property  of  all  cicatricial  tissue.  It  must 
contract,  and  with  this  contraction  drags  with  irresisti- 
ble force  whatever  is  attached  to  it,  including  the  ribs 
and  even  the  spinal  column,  which  is  sometimes  drawn 
out  of  line.  Thus  there  results  distortion,  in  various 
degrees,  of  the  shape  of  the  thorax,  associated  with  a 

*  Baccelli,  of  Rome,  in  1875,  suggested  a  method  of  distinguish- 
ing purulent  accumulations  from  serous.  He  found  that  the 
whispered  voice  was  often  audible  over  these  serous  accumulations, 
while  it  was  inaudible  over  pus  collections.  Douglas  Powell 
("Transactions  of  International  Medical  Congress,"  1881)  failed 
to  confirm  this  observation.  I  have  sometimes  noted  the  sign  under 
the  circumstances  described  by  BaccelH,  but  not  always. 


no  PHYSICAL    DLA. GNOSIS. 

shortness  of  breath  n^hich  is  permanent,  but  which  may, 
nevertheless,  grow  less  as  time  rolls  on. 

A  form  of  empyema  which  remains  to  be  alluded  to 
is  a  circumscribed  empyema  wherein  the  pus  is 
circumscribed  in  two  or  more  separate  or  communi- 
cating spaces.  It  is  not  always  easy  to  recognize  such 
a  state  of  affairs.  ]\Iost  frequently  it  is  ascertained 
by  the  attempt  at  the  removal  by  tapping,  the  with- 
drawal of  a  certain  amount  of  fluid  giving  partial 
relief  and  leaving  other  areas  with  physical  signs  un- 
changed.- Da  Costa  gives  us  from  Jaccoud  *  some 
points  to  assist  toward  such  recognition.  Given,  in  the 
area  of  dulness,  a  zone  along  which  vocal  vibrations  are 
preserved,  as  from  the  spinal  column  toward  the  sternum, 
a  separation  between  two  portions  of  fluid  probably 
exists  along  such  line.  When  the  diaphragm  is  adherent 
to  the  chest  wall  the  normal  movements  at  the  epigas- 
trium and  hypochondrium  are  reversed,  and  the  inspi- 
ration is  accompanied  by  depression  in  the  lower 
intercostal  spaces  instead  of  a  filling  out. 

One  other  feature  must  be  pointed  out  as  associated 
with  such  collections,  and  that  is  pulsation  sometimes 
communicated  to  them  by  the  heart.  Hence  the  term 
pulsating  empyema.  In  one  such  under  mv  care 
situated  below  the  left  clavicle,  the  pulsation  was  so 
striking  that  I  hesitated  to  puncture  it  lest  it  be  a  pul- 
sating auricle  or  an  aneurism.     The  knowledge  that  there 

*Da    Costa,   op.    cit,    p.    366,    from  Bulletin  de   rAcademie  de 
Midecine,  1879. 


PNEUMOTHORAX.  Ill 

was  pus  elsewhere  in  the  pleural  sac,  the  elevation  of 
temperature,  and  the  absence  of  sound  or  murmur  or 
thrill,  seemed  to  justif}^  operation,  and  a  large  quantity 
of  fetid  pus  was  drawn  through  a  communication  made 
with  a  pus  cavity  lower  down.  The  tumor  and  pulsation 
and  fever  disappeared,  and  the  patient,  who  was  a  girl, 
recovered.  This  situation,  the  upper  prsecordial  region, 
is  a  favorite  one. 

Other  Symptoms  of  Chronic  Pleurisy.— A 
fever  which  is  septic  is  almost  invariably  associated  with 
empyema,  causing  emaciation.  Shortness  of  breath  is 
also  constant.  Chronic  serous  effusions  are  not  com- 
monly attended  by  fever,  but  breathing  more  frequent 
than  normal  is  present. 


PNEUMOTHORAX. 

This  comparatively  frequent  complication  of  tuber- 
cular consumption  commonly  results  from  the  rupture 
into  the  pleural  sac  of  a  cavity  in  the  lung,  an  accident 
usually  brought  about  by  a  fit  of  coughing.  Sixty  to 
eighty  per  cent,  of  cases  are  said  to  be  due  to  tuber- 
culosis. After  this  comes  emphysema,  while  other  pos- 
sible causes  are  gangrene  and  ruptuie  of  subpleural 
abscess.  The  perforation,  is  followed  by  a  rapid  filling 
of  the  pleural  cavity  with  air,  which  is  soon  followed  by 
an  effusion  of  liquid,  at  first  seropuiulet,  but  sooner 
or  later  becoming  purulent.  The  result  is  a  distended 
air  sac,  occupied  to  a  certain  height  with  liquid,  com- 
pressing somewhat  the  lung  and  displacing  the  heart, 


1 1  2  PHYSICAL   DIAGNOSIS. 

while  the  physical  conditions  are  those  of  a  resounding 
cavity. 

The  effect  on  the  physical  signs  is  as  follows  :  To 
inspection  a  bulging  chest,  a  filling  out  of  the  intercostal 
spaces.  The  thoracic  wall  on  the  affected  side  dimin- 
ishes its  excursion  of  respiratory  movement,  or  it  ap- 
pears at  a  standstill.  Palpation  appreciates  no  vocal 
fremitus.  Percussion  furnishes  over  most  of  the  half 
of  the  thorax  involved  the  most  striking  of  the  percus- 
sion notes,  the  ringing,  amphoric  resonance,  which 
contrasts  strongly  with  the  absolute  dulness  due  to  the 
fluid  below.  When  the  patient  hes  on  his  back,  the 
portion  of  the  lung  floated  up  in  front  gives  good 
Skodiac  resonance,  while  a  striking  sign  is  the  marked 
lowering  of  the  dulness  in  the  recumbent  position,  a 
lowering  far  exceeding  that  noticed  in  a  simple  pleuritic 
effusion,  and  amounting  to  three  and  four  inches.  Bell 
tympany  may  also  be  elicited.  If  the  pneumothorax  is 
on  the  left  side  the  heart  may  be  pushed  over  to  the  right, 
and  if  on  the  right  the  liver  may  be  lowered.  To  aus- 
cultation the  normal  breathing  sounds  are  distant  and 
feeble,  the  expiratory  sound  continuing  short.  Along 
with  this  may  be  heard  amphoric  breathing  at  the  apex. 
The  voice  is  ringing,  amphoric,  and  an  unmistakable 
tinkling  sound  attends  the  dropping  of  fluid  from  the 
perforation  into  the  fluid  below,  or  a  similar  metallic 
character  may  be  given  to  rales  in  the  adjacent  tubes. 
A  sudden  shaking  of  the  body  produces  a  splashing 
sound  similarly  intensified  by  the  reechoing  to  which 
it  is  subjected, — the  Hippocratic  succussion  splash. 


PHYSICAL    EXAMINATION    OF    THE    HEART.  II3 

PHYSICAL   EXAMINATION   OF  THE 
HEART. 

Anatomical  Relations  of  the  Heart.  — The  actual 
boundaries  of  the  heart  in  the  chest  cavity  demand  some 
notice.  The  base  of  the  heart  is  held  fast  by  the  great 
vessels  coming  from  it,  but  the  remainder  of  the  organ 
has  a  certain  freedom  of  motion,  chiefly  rotary  but 
slightly  also  of  elongation,  but  limited  by  the  pericar- 
dial sac  attached  to  the  diaphragm  and  pleurae.  The 
heart  lies  with  its  right  ventricle  upon  the  central  tendon 
of  the  diaphragm.  The  auricles  are  nearly  transversely 
placed,  on  a  level  with  the  2d  interspaces  and  the  3d 
costal  cartilages,  both  extending  slighdy  beyond  the 
corresponding  borders  of  the  sternum.  The  ventricles 
are  obliquely  placed,  the  right  being  in  front  and 
directly  under  the  sternum,  extending  by  its  lowermost 
right-hand  corner  a  trifle  only  to  the  right  of  the  sternum 
at  the  5th  interspace,  and  considerably  to  the  left.  The 
right  ventricle  is  on  a  level  below  with  the  6th  carti- 
lage. A  much  smaller  portion  of  the  left  ventricle  is 
turned  to  the  front  when  the  heart  is  in  situ,  and  it  is 
altogether  within  the  line  of  the  nipple,  the  apex  corre- 
sponding to  a  point  between  the  5th  and. 6th  cartilages 
and  an  inch  to  i^  inches  below  and  within  the  nipple. 
The  base  of  the  heart  corresponds  behind  with  the  5th 
and  6th  dorsal  vertebrae,  between  which  and  it  he  the 
aorta  and  oesophagus.  The  heart,  surrounded  with  its 
pericardial  sac,  is  covered  very  largely  by  the  lungs,  the 
right  extending  to  the  middle  of  the  sternum,  the  left 


Th.  /''';  '^--P^^'""^'  °^  K^-^^'T  IN  Relation  to  Ribs  and  Sternu^ 

actuaUy  rSti'^^vitK"^  ,j^   placed   in   a  position   too   oblique.     The  heart 
Hule,  if aLroflL^e^^K'^t.Srst  tr^KtSe  ^^^^^     ^^ 


PHYSICAL    EXAMINATION    OF    THE    HEART.  1  T  5 

also  to  the  middle  as  low  as  a  line  continuous  with  the 
lower  edge  of  the  4th  cartilage,  along  which  it  passes; 
thence  obliquely  across  the  4th  interspace  and  the  5th 
rib,  the  lung  covering  the  whole  of  the  left  ventricle 
except  the  apex. 

The  size  of  the  heart  approximates  that  of  the  fist  of 
its  owner.  I  am  inclined  to  think  it  is  commonly  a 
little  larger.  Its  weight  in  adult  males  is  311. 6  grams 
(11  ozs.)  ;   in  females  255  grams  (9  ozs.). 

The  Prsecordium. — By  the  praecordial  region 
or  prsecordium  is  meant  that  portion  of  the  thoracic  wall 
covering  the  heart,  and  it  may  be  said  to  be  bounded 
above  by  a  line  drawn  through  the  junction  of  the  manu- 
brium with  the  blade  of  the  sternum,  below  by  a  line 
drawn  along  the  upper  edge  of  the  6th  cartilage,  and 
laterally  by  a  vertical  line  drawn  through  the  seat  of  the 
apex-beat,  and  another  3^  of  an  inch  to  the  right  of  the 
sternum.  In  this  region  inspection  and  palpation  rec- 
ognize the  apex-beat  between  the  5th  and  6th  ribs,  and 
lY^  inches  below  and  within  the  nipple.  In  children 
it  may  be  found  an  interspace  higher,  and  in  the  aged 
and  in  persons  with  long  and  narrow  thoraxes  it  may  be 
an  interspace  lower.  Occasionally,  in  the  2d  interspace 
to  the  left  of  the  sternum  in  thin  persons,  a  feeble  impulse 
can  be  seen,  produced  by  the  filling  of  the  left  auricle. 
The  situation  of  the  apex  is  slightly  altered  by  changes 
of  position  or  by  distension  of  the  stomach  from  any 
cause.  The  act  of  breathing,  however,  influences  it 
most.  With  a  deep  breath  the  heart  descends  and  is 
pushed    inward    by    the    inflated    lung,    and    the    apex 


1 1  6-  Pm-SICAL   DL4GN0SIS. 

approaches  the  epigastrium.  On  deep  expiration  it 
rises  shghtly,  and  while  the  breath  is  held  remains  higher. 
The  apex-beat  is  rendered  more  distinct  by  exercise  or 
emotion.  This  is  still  more  the  case  in  pathological 
states  where  there  is  enlargement.  Emphysema  of  the 
lungs  and  effusion  into  the  pericardial  sac  render  it 
more  or  less  indistinct.  Its  position  is  also  variously 
changed  by  morbid  conditions,  and  a  thrill  or  fremitus 
is  often  communicated  to  the  hand  in  valvular  diseases. 
Fremitus  is  also  sometimes  noticeable  as  the  result  of 
pericardial  friction.  The  whole  pr^ecordial  region  is 
sometimes  abnormally  prominent  in  hypertrophy  and 
pericardial  eft'usion,  especially  in  the  young,  while  re- 
traction due  to  adhesion  is  also  seen.  In  the  neighbor- 
hood of  the  prsecordium,  at  the  root  of  the  neck,  pul- 
sations, arterial  and  venous,  are  noted,  also  in  the  epi- 
gastrium, which  will  be  explained  under  the  head  of 
the  conditions  that  pjroduce  them. 


PERCUSSION  AND  AUSCULTATION  OF  THE 
NORMAL  HEART. 

The  percussion  boundaries  of  the  heart  have 
been  already  pointed  out  on  page  47,  but  it  may  not  be 
amiss  to  review  them  at  this  point  in  somewhat  further 
detail. 

To  map  out  the  percussion  border  of  the  heart,  we 
begin  percussing  on  a  horizontal  line  at  the  left  edge  of 
the  sternum,  at  about  the  2d  inteispace,  proceeding 
downward,  by  moderately  strong  percussion  only,  until 


Fig.  20.-SH0WING  Absolute  and  Relative  Percussion  Dulness  of  Liver 
A^'D  Heart. 

'"livel-^''?  ^.1^1"'''°"   <^"'".«^°f,  •'■^«-    ,^-   Absolute    percussion  dubess   of 
niss  of  heart!        ^"^"'"°"^^*''^    ^^''"-    4-  Absolute  percussion  dul- 


Il8  PEPi'SICAL    DIAGNOSIS. 

positive  duliiess  is  readied.  This  is  usually  found  to  be 
on  the  4th  costal  cartilage,  which  is  the  upper  border  of 
the  uncovered  area  of  the  heart,  and  where  a  line  should 
be  drawn.  Relative  or  deep  dulness  is  found  in  the 
interspace  or  on  the  rib  above.  We  then  begin  to  per- 
cuss on  a  vertical  line  at  Ihe  right  edge  of  the  sternum 
at  about  the  level  of  the  4th  rib,  and  proceed  across  the 
sternum  until  evident  dulness  is  reached,  which  is  in 
most  cases  toward  the  left  edge  of  the  sternum,  and  this 
is  the  right  border  of  the  absolute  dulness  of  the  heart, 
and  here  a  vertical  line  is  drawn.  Relative  dulness  is 
met  usually  at  the  right  edge  of  the  sternum  in  this 
situation.  The  situation  of  the  apex  is  then  found  by  pal- 
pation or  bv  the  stethoscope.  Percussion  is  again  com- 
menced on  an  oblique  line,  in  the  direction  of  a  line  from 
the  junction  of  the  4th  cartilage  with  the  sternum  toward 
the  apex,  but  sufificiently  beyond  to  be  certain  of  clear- 
ness. Then,  parallel  with  such  a  line,  proceed  downward 
until  positive  dulness  is  reached.  The  lower  border  of 
the  heart  cannot  be  satisfactorily  separated  by  percus- 
sion from  the  liver,  but  such  a  boundary  can  be  obtained 
with  sufificient  accuracy  by  drawing  a  line  from  the  apex 
perpendicular  to  the  sternum.  By  the  phonendoscope, 
however,  the  line  of  demarcation  between  the  two 
organs  can  be  found.  Thus  the  area  of  absolute 
dulness  in  adults  will  correspond  to  a  rude  triangle,  of 
which  the  base  is  2  to  2j^  inches,  the  perpendicular 
2  inches,  and  the  hyporhenuse  3}^  to  4  inches  on  a 
somewhat  curved  line. 

The  area  of  relative  dulness,  elicited  by  stronger 


PERCUSSION    AND    AUSCULTATION    OF    HEART.  II9 

percussion,  extends  a  short  distance  beyond  tine  bounda- 
ries indicated  in  every  direction  except  downward.  Ttie 
exact  measure  of  this  must  depend  somewhat  on  the 
delicacy  of  the  ear  of  the  examiner  and  the  mode  in 
which  he  percusses,  but  it  may  be  put  down  approxi- 
mately as  a  finger's  breadth,  and  on  the  left  side  still 
within  an  oblique  line  draw.n  through  the  nipple  in 
adults. 

Various  causes  influence  the  area  of  cardiac  percussion 
dulness  in  health.  In  children,  the  area  of  the  cardiac 
dulness  is  decidedly  reduced  on  account  of  the  intense 
resonance  of  the  child's  thorax.  In  old  age,  on  the' 
other  hand,  the  area  of  absolute  cardiac  dulness  is 
increased  on  account  of  the  shrinkage  of  the  lungs. 
The  upper  border  of  absolute  dulness  may  be  at  the 
3d  rib,  and  the  apex  may  be  in  the  6th  interspace. 
The  effect  of  a  deep  inspiration  is  materially  to  dimin- 
ish the  area  of  dulness,  while  that  of  expiration  en- 
larges it. 

Pathologically  the  normal  area  is  increased  downward 
to  the  left  in  hypertrophy  of  the  left  ventricle,  down- 
ward toward  the  epigastrium  and  to  the  right  in  hyper- 
trophy of  the  right  ventricle. 

Auscultation  of  the  normal  heart  is  very  simple. 
By  it  we  recognize  the  normal  heart-sounds,  known 
as  first  and  second.  Both  sounds  are  audible  over 
he  whole  praecordial  region  in  health,  but  the  first 
sound,  characterized  by  its  longer,  booming  character 
and  lower  pitch,  is  heard  most  loudly  at  the  seat 
of    the   apex-beat,  where    it   is   the   louder   of    the    two. 


I20  PHYSICAL   DLA.GNOSIS. 

The  second — shorter,  sharper,  higher  pitched,  and 
more  snapping  in  character — is  most  intense  at  the  base 
of  the  heart,  on  the  stermnn  opposite  the  2d  interspace. 
Both  sounds  are  heard  at  both  situations,  but  each  has 
its  situation  of  greatest  loudness.  Hence,  at  the  apex 
the  rhythm  may  be  said  to  be  represented  by  the  tro- 
chaic foot  —  ^^ ,  while  at  the  base  it  is  represented  by 
the  iambus  ^  • — .  The  two  sounds  have  also  been 
long  compared  to  the  word  hib-tiip,  the  fiist  syllable 
corresponding  to  the  first  sound  and  the  second  to  the 
second  part.  While  this  word  cannot  be  said  to  re- 
semble the  heart  sounds  very  closely,  there  seems  to  be 
no  other  that  resembles  them  more. 

As  to  the  mechanism  of  the  sounds,  while  that  of 
the  first  is  probably  somewhat  complex, — including  the 
shutting  down  of  the  auriculo-ventricular  valves,  the 
apex-beat,  the  rush  of  blood  through  the  aorta  and 
pulmonary  artery,  and  the  noise  of  muscular  con- 
traction,— it  is  sufficient  for  clinical  purposes  to  consider 
it  produced,  as  it  is  for  the  most  part,  by  the  shutting 
down  of  the  auriculo-ventricular  valves,  the  mitral 
or  bicu-spid  on  the  left  side  and  the  tricuspid  on  the 
right.  Both  sets  of  valves  shut  down  sinrultaneously, 
both  contribute  to  the  production  of  the  sound,  while 
the  greater  muscular  power  of  the  left  side  gives  to  it  a 
distinct  predominance. 

The  second  sound  is  of  simpler  mechanism,  and  is 
caused  solely  by  the  shutting  down  of  the  semilunar 
valves  of  the  aorta  and  pulmonary  arter}',  with  the  recoil 
of    the   blood  upon   them.     On  account  of    the   more 


PERCUSSION    AND    AUSCULTATION    OF    HEART.  121 

powerful  recoil  in  the  aorta,  the  aortic  is  the  predomi- 
nating sound. 


Fig.  21. — Diagram  Showing  the  Location  of  Cardiac  Valves  and  Points 
OF  Maximum  Intensity  CoNNjiCTED  with  Them. 

The  triangle,  a  b  c,{s  the  area  of  superficial  or  absolute  dulness.  A  corresponds 
to  the  anatomical  seat  of  the  aortic  valves,  P  to  the  pulmonary,  M  to  the 
mitial,  T  to  the  tricuspid.  The  points  of  greatest  intensity  of  the  sounds  are 
ai  iox  the  aortic, /z' for  the  pulmonary,  m  for  the  mitral,  t  for  the  tricuspid. — 
{After  Page.) 


We  may  isolate  the  part  played  by  each  set  of  valves 
by  carrying  the  stethoscope  to  certain  situations,  and  in 


122  PHYSICAL    DIAGNOSIS. 

diagnosis  constant  advanage  is  taken  of  this.  Thus, 
in  order  to  pick  out  the  mitral  part  of  the  first  sound, 
the  stethoscope  is  placed  at  the  seat  of  the  apex-beat, 
while  the  tricuspid  factor  is  best  heard  at  the  left  sternal 
border,  between  the  5th  and  6th  cartilages.  So  with 
the  second  sound,  the  aortic  factor  is  best  heard  at  the 
2d  interspace  to  the  right  edge  of  the  sternum;  and 
the  cartilage  just  above  this  is  known  as  the  aortic 
cartilage,  because  this  great  vessel  approaches  next  to 
the  chest-wall  in  this  situation.  The  pulmonary  part 
of  the  sound,  on  the  other  hand,  is  heard  at  the  left 
edge  of  the  sternum  at  the  2d  interspace,  while  the 
cartilage  above  this,  behind  which  ascends  the  pulmon- 
ary artery,  is  called  the  pulmonary  cartilage.  These 
points,  and  a  circle  about  an  inch  in  diameter  around 
them,  are  known  as  the  mitral,  tricuspid,  aortic,  and 
pulmonary  areas. 

Topography  of 'the  Valves. — It  is  to  be  remem- 
bered, however,  that  these  are  not  the  precise  seats  of 
the  valves  themselves.  These  are  all  situated  in  won- 
derfully close  proxin:iity  to  each  other — in  fact,  a  por- 
tion of  each  is  contained  within  a  space  of  less  tlian  ^ 
inch  square.  The  mitral  valve  is  placed  behind  all 
the  others,  at  a  point  toiresponding  to  the  left  border 
of  the  sternum  at  the  3d  interspace.  It  lies  almost  hori- 
zontally about  Y^  inch  below  the  attachment  of  the 
aortic  valves.  The  tricuspid  valve  corresponds  to  a 
line  drawn  obliquely  across  the  sternum  from  the  3d  left 
interspace  to  the  5th  costal  cartilage  of  the  opposite 
side.     The   aortic    valve  lies  nearly   horizontally  be- 


PERCUSSION    AND    AUSCULTATION    OF    HEART.  1 23 

hind  a  line  joining  the  middle  of  the  sternum  and  the 
end  of  the  3d  left  costal  cartilage.  The  pulmonary 
valve,  a  little  higher  and  to  the  left  of  the  aortic,  runs 
quite  horizontally,  corresponding  to  a  line  drawn  along 
the  upper  border  of  the  3d  left  costal  cartilage.  Thus 
all  of  the  valve  attachments  except  the  tricuspid  are 
horizontal  or  very  nearly  horizontal.  The  want  of  iden- 
tity of  the  auditory  valve  area,  or  place  where  the 
sounds  are  best  isolated,  with  the  actual  sites  of  the 
valves,  is  due  to  the  fact  that  the  sounds  are  best  heard 
at  points  on  the  chest-walls  nearest  the  cavity  or  chan- 
nel in  which  vibrating  blood  is  flowing. 

The  normal  heart-sounds  are  heard  less  loudly  over 
the  normal  areas  during  deep  inspiration,  when  they 
are  more  completely  covered  by  the  fully  expanded 
lungs,  and  the  first  sound  is  heard  more  loudly  at  a  new 
point  toward  the  median  line,  to  which  the  apex  is 
pushed  by  the  inflated  lungs.  On  the  other  hand, 
forced  expiration  increases  the  area  over  which  the 
sounds  are  heard. 

The  time  of  the  normal  heart- sounds  requires  some 
further  study,  because  on  a  thorough  understanding  of 
this  depends  largely  skill  in  diagnosis.  The  first  sound 
begins  with  the  systole  of  the  ventricles  and  is  coinci- 
dent with  the  apex-beat;  the  second  occurs  in  the  dias- 
tole, immediately  after  the  first,  with  a  short  pause 
between.  The  second  sound  is  succeeded  by  a  longer 
pause  occupied  with  the  diastole  of  the  ventricles,  during 
the  latter  part  of  which  occurs  the  systole  of  the  auricles, 
terminating  the  diastole  of  the  ventricles.     Thus,  if  a 


124  PHYSICAL   DL4GN0SIS. 

revolution  of  the  heart's  sounds  and  pauses  be  repre- 
sented by  a  dash  and  interspaces  we  will  have  the  fol- 
lowing: : 


P^  2d  &-  Pi  2d  P-i 

ist   sound     tJ   sound       tjo  ist  sound     t;  sound       M 


I  I  I  I  I  I  M  I  I   I  I  I  I  I  I 
1234  5  6789  10  123  4  56789  10 


of  which  the  first  sound  will  occupy  four-tenths,  the 
short  pause  one-tenth,  the  second  sound  two-tenths, 
and  the  long  pause  three-tenths. 

It  is  to  be  remembered  that  each  one  of  these  sounds 
is  double,  two  systolic,  occurring  at  the  ventricular  ori- 
fices, and  two  diastolic,  at  the  aortic  and  pulmonary 
orifices.  It  may  be  further  conceded  that  the  first 
sound  as  heard  at  the  base  of  the  heart  and  the  second 
sound  as  heard  at  the  apex  are  simply  conducted  from 
the  seat  of  their  production,  and  that  they  are  in  no 
part  produced  at  the  situation  where  they  are  less  loud. 


ABNORMAL    MODIFICATIONS   OF  HEART- 
SOUNDS. 

It  is  not  impossible,  even  in  health,  to  have  these 
paired  sounds  separated,  and  thus  is  produced  what  is 
known  as  reduplication  of  the  heart-sounds,  a  phe- 
nomenon more  common  in  diseases  of  the  heart.  Thus, 
as  the  effect  of  running  there  may  result  such  an  en- 
gorgement of  the  lesser  circulation  and  high  tension  in 


ABNORMAL    MODIFICATIONS    OF    HEART-SOUNDS.         1 25 

the  pulmonary  artery,  that  the  pulmonary  valve  closes  a 
little  sooner  than  the  aortic,  and  reduplication  of  the 
second  sound  occurs.  In  like  manner  the  closure  of  the 
tricuspid  valve  may  be  retarded,  the  synchronism  de- 
stroyed, and  reduplication  of  the  first  sound  thus  pro- 
duced. Intermission  is  an  almost  constant  feature  of 
reduplication,  the  double  sound  occurring  with  certain 
beats  of  the  heart,  with  others  not.  This  intermission 
has  a  close  relation  with  the  movements  of  respiration. 
Thus  the  first  sound  is  reduplicated  at  the  end  of  expira- 
tion and  beginning  of  inspiration,  the  second  at  the  end 
of  inspiration  and  the  beginning  of  expiration.  The 
same  and  similar  conditions  operate  to  produce  redupli- 
cation of  the  heart-sounds  in  disease.  In  labored 
breathing  the  order  of  reduplication  is  reversed,  the 
first  sound  being  doubled  at  the  end  of  inspiration  and 
beginning  of  expiration,  and  the  second  sound  at  the 
end  of  expiration  and  beginning  of  inspiration. 

The  intensity  of  the  heart-sounds  is  greater  in  per- 
sons with  thin  chest-walls  and  under  the  influence  of 
excitement.  Abnormally  the  feverish  state  and  general 
hypertrophy  have  the  same  effect,  but  the  latter  is  more 
apt  to  influence  the  sound  of  the  particular  cavity  which 
is  hypertrophied.  The  heart-sounds  are  often  heard 
with  unusual  distinctness  at  points  distant  from  their 
normal  areas  because  of  consolidation  of  adjacent 
lung,  and  sometimes  inexplicably.  Intensification  or 
accentuation,  as  it  is  called,  of  the  aortic  or  pul- 
monary element  of  the  second  sound  is  caused  by 
whatever  produces   increased  tension  in  the  arterial  or 


126  PHYSICAL    DIAGNOSIS. 

pulmonary  circulations.  Heart-sounds  are  also  some- 
times made  ringing  by  their  proximity  to  a  cavity  with 
firm  walls  or  even  a  tensely  distended  stomach. 

Abnormally,  heart-sounds  are  rendered  less  intense 
by  general  and  cardiac  weakness,  fatty  degeneration  of 
the  myocardium,  pericardial  and  pleural  effusions,  and 
emphysematous  lungs,  which  cover  up  the  heart  more 
completely. 

Abnormal  heart-sounds  or  murmurs  are  modi- 
fications of  the  normal  sounds,  either  superadded  to 
them  or  altogether  substituting  them.  These  are  pro- 
duced within  the  cavity  of  the  heart,  and  are  accord- 
ingly known  as  endocardial.  In  addition  an  altogether 
new  sound  is  engendered  external  to  the  heait,  and 
therefore  called  exocardial  or  pericardial.  To  this  the 
term  m.urmur  is  also  applied,  although  the  mechanism 
of  its  production  is  so  widely  different  it  does  not  seem 
to  me  desirable  to  perpetuate  the  practice. 

The  endocardial  abnormal  sounds,  or  heart 
murmurs,  are  sounds  due  to  alteration  in  the  con- 
ditions of  normal  blood  currents,  produced  either  by 
structural  changes  in  the  heart,  its  valves,  or  in  the 
composition  of  the  blood. 

The  former  are  called  organic  murmurs,  the  latter 
functional  or  accidental.*     Both  are  due  to  vibra- 


*  The  term  inorganic  is  sometimes  applied  to  the  fur.ctional  mur- 
murs, but  this  word  has  another  meaning  so  definite,  that  of  mineral, 
that  it  seems  almost   misleading  to  apply  it  in  the  sense  referred 

to  in  the  text. 


ABNORMAL    MODIFICATIONS    OF    HEART-SOUNDS.         1 27 

tions  or  oscillations  in  the  blood  stream  produced  by 
the  causes  referred  to,  and  not  to  a  friction  between  the 
blood  current  and  the  narrowed  orifices  or  inequalities 
on  the  valves.  Hydraulic  laws  teach  us  that  when  a  fluid 
passes  through  a  tube  the  inner  suiface  of  which  it 
wets,  a  thin  film  of  fluid  becomes  attached  to  this  sur- 
face, over  which  the  remainder  of  the  fluid  moves  with- 
out friction.  So  it  is  with  the  cardiac  cavity  and  its 
valves  over  which  the  blood  moves.  Further,  while  a 
fluid  passing  along  a  tube  of  uniform  diameter  at  a 
moderate  speed,  no  murmur  results,  whether  the  inner 
wall  of  the  tube  te  smooth  or  rough.  A  murmur  is  only 
produced  when  the  tube  becomes  suddenly  narrower 
and  then  widens  again,  and  the  greater  the  narrowing 
the  less  speed  of  current  required  to  produce  the  mur- 
mur. Thus  the  vibrations  arise,  and  thus  the  sound  is 
produced. 

In  the  case  of  functional  murmurs,  which  apparently 
occur  without  the  intermediation  of  sudden  narrowing, 
we  must  suppose  such  a  change  in  the  composition  of 
the  blood  either  as  to  its  density  or  viscidity,  which 
permits  it  to  be  more  readily  thrown  into  vibration.  In 
either  event  there  is  a  derangement  of  that  adaptation 
of  the  column  of  blood  to  the  orifices  and  cavities 
through  which  it  has  to  pass,  which  ordinarily  per- 
mits the  function  of  the  heart  to  be  performed  noise- 
lessly except  so  far  as  its  normal  sounds  are  concerned. 
In  the  case  of  the  organic  murmurs  the  alteration  is 
produced  by  the  various  valvular  defects  to  which  the 
heart  is  subject,  in  that  of  the  functional  murmurs  by 


126  PHYSICAL   DIAGNOSIS. 

the  various  anaemias  'which  are  principally  associated 
with  such  murmurs.  The  true  valvular  murmurs  may- 
be intensified  by  conditions  of  the  blood. 

It  should  be  mentioned  that  Ernest  Sansom  considers 
that  the  vibration  of  solids  is  by  far  the  most  important 
in  the  generation  of  murmurs,  the  influence  of  fluids 
being  intermediate,  and  not  immediate.* 


ORGANIC   MURMURS. 

An  organic  murmur  may  be  produced  at  any  one  of 
the  four  cardiac  orifices,  mitral,  tricuspid,  aortic,  or 
pulmonary.  They  are  far  more  common  at  the  mitral 
and  aortic. 

Murmurs  are  also  classified  as  systolic,  diastolic,  and 
presystolic.  Systolic  murmurs  occur  during  the  sys- 
tole of  the  ventricles,  diastolic  murmurs  during  their 
diastole  and  alternate  with  the  apex-beat.  A  diastolic 
murmur  which  immediately  precedes  the  systole  is 
called  a  presystolic  murmur.  Murmurs  are  further 
classified  as  direct  and  indirect.  Direct  murmurs  are 
those  which  arise  in  the  blood  current  as  it  is  flowing  in 
the  normal  direction  ;  indirect  are  those  which  arise 
in  a  current  flowing  opposite  to  the  natural  direction. 
The  order  in  which  murmurs  are  considered  is  of  little 
importance.  Their  great  frequency  seems  a  sufficient 
reason  for  taking  up  mitral  murmurs  first. 

*  "Diagnosis  of  Diseases  of  Heart  and  Aorta,"  Philadelphia, 
1892,  p.  236. 


ORGANIC    MURMURS.  I  29 

Mitral  Murmurs.— 7%^  Mitral  Systolic  or  Mitral 
Indirect  Murmur. — During  the  systole  of  the  ventricles 
the  auriculo-ventricular  orifices  in  a  perfect  heart  are 
closed    in    order    to    prevent    the    return   of   blood    to 


Fig.  22. — Mitral  Systolic  Murmur,  Propagated  in  Front. 
{After  Hutchison  and  Rainy.) 


the  auricles,  while  the  aortic  and  pulmonary  orifices  are 
wide  open  to  permit  the  blood  to  enter  these  great  ves- 
sels, and  the  ear  placed  at  the  apex  hears  mainly  the 
first  sound.  If,  however,  there  be  a  defect  in  the  mitral 
valve,  as  the  result  of  which  it  closes  imperfectly,  then, 
during  the   systole   a   stream   of  blood  will  flow  back- 


I30 


PHYSICAL   DIAGNOSIS, 


ward  into  the  left  auricle  accompanied  by  a  murmur. 
This  is  the  mitral  systolic  murmur,  and  it  means  incom- 
petency or  insufficiency  of  the  valve  with  consequent 
regurgitation  of  blood.  The  mitral  systolic  murmurs 
are  almost  invariably  best  heard  in  the  mitral  area  at  the 


S.S5/ 


Fig.  21 


-Mitral  Systolic  Murmur,  Propagated  Behind. 
{After  H-utchiso7i  and  Raiiiy.') 


apex,  and  are  conducted  into  the  left  axilla  and  under 
the  angle  of  the  left  scapula.  Rarely,  however,  they 
are  heard  just  to  the  left  of  the  pulmonary  area,  prob- 
ably because  the  vibrations  are  conducted  into  the  ap- 
pendage of  the  auricle  and  are  best  heard  where  this 


ORGANIC    MURMURS.  13  X 

approaches  nearest  the  surface,  namely,  i>^  inches  to 
the  left  of  the  pulmonary  area.  This  occurs  more  fre- 
quently, too,  with  functional  murmurs. 

Mitral  Diastolic  and  Presystolic  Murmurs,  or  Mitrat 
Direct  Murmurs. — During  the  diastole  of  the  ventricles 
the  aortic  orifice  is  closed  and  the  mitral  orifice  open, 
and  the  blood  flows  noiselessly  into  the  left  ventricle, 
the  filling  of  which  is  finally  completed  by  the  systole 
of  the  auricle.  If,  however,  the  mitral  orifice  be  nar- 
rowed from  any  cause,  the  blood  column  is  thrown  mto 
vibration  and  a  murmur  results— a  diastolic  murmur. 
When,  as  frequently  happens,  the  narrowing  or  stenosis 
is  not  sufficient  to  cause  a  murmur  throughout  the  entire 
diastole,  but  only  when  the  additional  momentum  is 
given  to  the  blood  by  the  systole  of  the  auricle,  a  mur- 
mur occurs  only  at  this  time — that  is,  just  before  the 
systole  commences.  It  is  then  called /;rj;j'^/^/zV.  These 
murmurs  mean,  therefore,  mitral  stenosis,  which  is, 
however,  generally  associated  with  incompetency  of  the 
mitral  valve. 

The  systolic  mitral  murmur  is,  for  the  most  part, 
soft,  but  may  have  every  variety  of  character  and 
be  high  pitched  or  low  pitched,  but  the  presystolic 
is  always  rough,  and  is  variously  characterized  as  rat- 
tling, rolling,  churning,  grinding,  blubbering,  and 
bubbling,  being  compared  to  the  vibration  in  the  hps 
caused  by  blowing  the  breath  through  them.  The 
sound  is  further  characterized  by  its  abrupt  termination, 
although  this  is  not  invariable.  It  may  also  disappear 
for  a  time  or  even  altogether.     A  presystohc  thrill,  felt 


132  PHYSICAL   DL\GNOSIS 

at  the  apex  of  the  heart,  often  accompanies  the  murmur. 
The  presystolic  murmur  is  best  heard  in  the  ■  mitral 
area,  and  is  not,  as  a  rule,  conducted  thence  in  any  direc- 
tion. Sometimes  the  murmur  is  heard  slightly  to  the 
right  of  the  apex. 


Fig.  24. — Mitral  Presystolic  Murmur. — (After  Htitchiso7L  and  Rahiy.) 

A  diastolic  murmur  heard  in  the  mitral  area  may  also 
be  due  to  aortic  regurgitation,  the  sound  being  con- 
ducted from  the  seat  of  its  production  to  the  apex. 
This  is  a  frequent  matter  of  niisinterpretatio:i.~  It  is 
often  difficult  to  differentiate  the  presystolic  murmur 
from  a    svstoHc    mitral  murmur  Avhen,  as  is    often  the 


ORGANIC    MURMURS.  1 33 

case,  the  two  are  associated,  the  presystoHc  murmur 
passing  indistinguishably  into  the  systolic  murniur. 
The  difficulty  is  further  increased  because  in  mitral 
stenosis  the  first  sound  is  usually  short,  resembling  the 
second.  The  point,  therefore,  is  to  get  the  exact  time 
of  the  murmur  by  noting  carefully  its  anticipation  of 
the  apex-beat  or  the  carotid  pulse.  The  so-called 
Flint's  murmur  also  closely  resembles  the  murmur  of 
mitral  stenosis,  and  the  infrequency  of  the  latter  alone 
prevents  more  mistakes.  This  murmur  is  heard  at  the 
apex,  the  same  site  as  the  presystolic,  and  may  be  simi- 
lar in  quality.  It  is  said  to  occur  with  high  degrees  of 
dilatation  of  the  ventricle,  and  is  due  to  the  fact  that  in 
such  dilatation  the  mitral  leaflets  cannot  during  diastole 
be  kept  back  against  the  ventricle  wall,  but  remain  in 
the  blood  current,  throwing  the  latter  into  audible 
vibration. 

Mitral  diastolic  murmurs  are  not  always  presystolic. 
More  rarely  they  follow  immediately  on  the  second 
sound,  when  they  are  called  simply  diastolic.  lu  other 
instances  they  are  mid-diastolic,  being  separated  from 
the  second  sound  by  a  brief  interval;  in  others  still 
there  is  a  brief  interval  between  the  diastolic  and  pre- 
systolic murmurs.  These  are  refinements  which  can 
only  be  made  by  the  skilled  ear.  They  are  always 
organic. 

Aortic  Murmurs. — Aortic  Systolic  or  Aortic  Direct 
Murmur. — During  the  systole  of  the  ventricles  in  health 
the  aortic  orifice  is  wide  open,  and  the  blood  flows 
noiselessly  through    it.     If   any    interference   with    the 


134 


Pm^SICAL    DIAGNOSIS. 


complete  opening  of  the  orifice  or  roughness  or  in- 
equalit^v  exists,  the  stream  of  blood  is  thrown  into  vibra- 
tion, and  the  aortic  systolic  murmur  results,  heard  at 
the  base  of  the  heart  in  the  aortic  area.  Such  a  mur- 
mur, therefore,  means  narrowing   or  stenosis  of    the 


Fig.  25.— Aortic  Systolic  Murmur  and  its  Propagation. — {After  Hutchison 
and  Rainy ^ 


aortic  orifice  or  roughening  at  the  beginning  of 
the  aorta.  It  is  generally  loud  and  harsh,  sometimes 
musical,  heard  most  loudly  in  the  aortic  area — second 
right  interspace — but  generally  all  over  the  praecordium. 
It  is  conducted  into  the  great  vessels  of  the  neck  with 
great  intensit}'. 


ORGANIC    MURMURS.  1 35 


Aortic  Diastolic  o?-  Aortic  Indirect  Alurmur. — During 
diastole  the  aortic  orifice  should  be  closed  and  imper- 
meable to  blood.  If,  however,  as  the  result  of  disease, 
perfect  closure  be  impossible,  a  stream  of  blood  will 
flow  backward  into  the  left  ventricle,  accompanied  by 


Fig.  26. — Aortic  Diastolic  Mukmur  and  its  Seats  of  Propagation. — 'After 
Hutchison  and  Rainy.) 


a  murmur  at  the  base  of  the  heart,  which  is  the  aortic 
diastolic  murmur,  and  means  always  insufficiency  or 
incompetency  of  the  aortic  valve.  This  murmur 
more  or  less  replaces  the  second  sound  of  the  heart,  is 
generally  loud,  long,  and  blowing,  though  less  harsh  than 
the  aortic  systolic  miirmur^  and  varies  more  in  the  seat  of 


136  PHYSICAL    DLA.GNOSIS. 

its  intensity  and  condition  than  any  other  cardiac  mur- 
mur. It  is  sometimes  loudest  in  the  aortic  area,  but  often 
over  the  niidstemum,  and  it  is  even  well  heard  as  low- 
as  the  ensiform  cartilage,  or  at  the  apex  itself.  It  has 
been  mistaken  in  this  situation  for  a  presystolic  mitral 
murmur.  It  is  also  transmitted  downward  along  the 
sternum  and  toward  the  apex,  because  it  is  in  this 
direction  that  the  column  of  regurgitant  blood  is 
moving.  It  is  accompanied  by  a  powerful  heaving 
impulse  and  the  striking  trip-hammer  or  Corrigan 
pulse  characterized  by  its  rapid  rise  and  sudden  fall.  It 
also  occurs  alone,  but  is  frequently  associated  with  the 
aortic  systolic  murmur,  indicating  stenosis  or  roughen- 
ing or  deformity  of  the  valve-segments.  Thus  is  pro- 
duced the  double,  sawing,  or  steam-tug  murmur. 

Murmurs  in  the  Right  Side  of  the  Heart. — 
The  same  conditions  at  the  valve-oiifices  on  the  right 
side  of  the  heart  produce  similar  murmurs,  but  they  are 
very  much  rarer.  Thus  tricuspid  regurgitation  pro- 
duces the  tricuspid  systolic  murmur,  and  tricuspid 
stenosis  produces  the  tricuspid  presystolic  murmur. 
These  are  heard  in  the  tricuspid  area  at  the  lower  part 
of  the  sternum,  at  its  junction  with  the  5  th  and  6th  car- 
tilages. Tricuspid  regurgitation  is  apt  to  occur  sooner 
or  later  in  connection  with  mitral  disease,  but  indepen- 
dent of  mitral  diseases  it  is  very  rare,  being  generally 
congenital.  (See,  however,  page  169.)  Pulmo nary- 
stenosis  scarcely  occurring,  except  congenitally,  pro- 
duces the  pulmonary  systolic  murmur,  and  pulmonary 
regurgitation,  the  rarest  of  all,  would  produce  a  dias 


ORGANIC   MURMURS.  1 37 

tolic  murmur.  Both  are  heard  in  the  puhnonary  area 
at  the  second  interspace,  at  the  left  edge  of  the  sternum. 

Impurity  of  Heart-Sounds. — In  addition  to  the 
easily  recognizable  abnormal  sounds  described^  there 
occur  more  or  less  marked  modifications  of  the  normal 
sounds  due  to  slight  defects  of  the  valves,  which  render 
them  less  typical,  whence  the  term  impurity  of  heart- 
sound.  They  may  be  caused  by  slight  thickenings  or 
other  changes  which  modify  the  normal  closure  of  the 
valves,  and  are  of  uncertain  significance.  On  the  other 
hand,  very  decided  alterations  in  the  valves  and  orifices 
are  sometimes  found  at  necropsy  when  no  modifications 
of  the  normal  sounds  were  detectable  during  life. 

The  Exocardial  or  Friction  Sound. — The  only 
true  exocardial  murmur  is  the  pericardial  friction 
sound  caused  by  rubbing  of  the  two  surfaces  of  the  peri- 
cardium upon  each  other,  in  health  a  noiseless  act  like 
that  of  the  pleural  surfaces.  When  roughened,  however, 
by  disease  a  to-and-fro  sound  of  varying  loudness  and 
harshness  is  produced.  The  most  frequent  cause  is  peri- 
carditis, but  any  cause  which  roughens  the  two  opposite 
surfaces,  such  as  tubercular  and  other  morbid  growths, 
will  produce  a  friction  sound 

The  friction  sound  sometimes  resembles  the  intracar- 
dial  murmur,  but  a  little  experience  enables  one  to  dis- 
tinguish them.  The  friction  sound  is  a  superficial  to- 
and-fro  sound  heard  directly  under  the  ear,  commonly 
loud  and  rasping,  never  blowing,  sometimes  creaking. 
It  is  most  loud  over  the  middle  of  the  heart,  not  syn- 
chronous with  the  normal  heart-sounds   and    not  con- 


138  PHYSICAL    DIAGNOSIS. 

ducted  in  the  direction  of  the  blood  current.  It  is  often 
influenced  by  changes  of  position  or  by  breathing,  or 
by  pressure  with  the  stethoscope.  It  may  sometimes 
be  felt  by  the  hand  placed  over  the  heart.  It  is  gen- 
erally of  short  duration  and  disappears  with  the  filling 
of  the  pericardium  by  effusion. 

A  friction  may  be  pleuropericardial,  that  is,  given  a 
circumscribed  pleurisy,  the  pericardium  in  its  motion 
over  the  rough  surface  of  the  pleura  may  produce  a  fric- 
tion sound  simulating  the  pericardial  friction,  but  such 
sound  ceases  with  the  compelte  holding  of  the  breath. 

A  churning  or  water-wheel  sound  is  produced 
when  air  and  water  are  both  present  in  the  pericardium, 
— a  rare  event. 

Cardio-respiratory  murmurs  are  s3stolic  mur- 
murs heard  at  the  end  ot  a  full  inspiration,  and  are 
caused  by  the  heart's  impulse  forcing  with  its  contrac- 
tion the  air  out  of  sorne  adjacent  air-vesicles,  or  possibly 
even  a  cavity.  The  sound  resembles  a  soft  systolic 
murmur,  but  ceases  when  the  breath  is  held  in  expira- 
tion.    Similarly  caused  2st  pulsating  crepitations. 


FUNCTIONAL,  OR   ACCIDENTAL,   OR   H^EMIC 
MURMURS. 

These  are  murmurs  usually  supposed  to  arise  indepen- 
dently of  any  abnormality  in  the  state  of  the  cardiac 
valves  or  orifices.  They  have  certain  characters  by 
which  they  are  commonly  distinguished  from  organic 
murmurs,  although  such  distinction  is  not  always  easy. 


FUNCTIONAL,  ACCIDENTAL,  OR  H^MIC    MURMURS.        1 39 

I.  They  are  invariably  systolic.  2.  They  are  almost 
always  soft  and  blowing,  and  greatly  influenced  by  pos- 
ture, being  more  pronounced  in  the  recumbent  position 
than  in  the  upright,  although  this  relation  is  sometimes 
reversed.  3.  They  are  most  frequently  basic,  and  far 
more  common  pulmonary  than  aortic,  but  occasionally 
they  are  heard  at  the  apex.  4.  Functional  murmurs  are 
unattended  by  the  unequal  distribution  of  blood  and  the 
alteration  in  the  size  of  the  heart  and  its  cavities,  which 
always,  sooner  or  later,  accompany  the  organic  mur- 
murs. 

They  have  therefore  been  regarded  as  due  I0  some 
condition  of  the  blood,  as  the  result  of  which  its  parti- 
cles are  thrown  into  vibration  more  readily  than  in 
health.  Hence  they  are  also  called  hczmic  murmurs. 
Such  condition  is  generally  accompanied  by  a  watery 
state  of  the  blood ;  for  this  reason  they  are  also  called 
anaemic  murmurs,  being  especially  frequent  in  anaemia 
and  chlorosis,  and  in  women  immediately  after  child- 
birth. Whether  it  be  this  thinness  of  the  blood  which 
is  repponsible  for  the  murmur,  or  some  accompaniment 
of  such  a  state  is  not  known. 

These  murmurs  also  occur  in  connection  with  various 
morbid  states  of  the  blood,  such  as  exist  in  the  infec- 
tious fevers  as  well  as  the  various  anaemias  ;  also  in  certain 
neuroses,  especially  in  Graves'  disease  and  allied  affec- 
tions. In  these  latter  there  are  also  arterial  murmurs, 
which  are  ascribed  to  vasomotor  influences  producing 
inequalities  of  calibre  of  the  vessel,  which  engender 
murmurs.     From  these  facts  Sansom's  theory  ascribes  to 


140  PHYSICAL   DL4GN0SIS. 

a  similar  origin  the  murmurs  in  the  great  vessels  in  neu- 
roses and  anaemia.  The  ventricle,  weakened  by  im- 
paired nerve  force,  toils  to  overcome  an  unusual  resist- 
ance due  to  tension  in  the  great  vessels,  and  the  muscular 
fibrillse  of  the  conns  of  the  ventricle  just  below  the 
valves  are  thrown  into  tremor.  The  valves  themselves 
may  vibrate,  and  these  vibrations  are  communicated  to 
the  area  of  the  thoiax  adjacent  to  these  vessels  through 
the  portions  of  these  vessels  immediately  above  the 
valves.  The  right  ventricle  and  its  conus  are  moie 
superficial,  its  muscular  walls  are  thinner,  and  in  the 
conditions  named  it  has  to  contend  against  relatively 
greater  obstruction,  hence  murmurs  at  its  site  are  more 
frequent.* 

Natmyifs  theory  ascribes  the  so  called  pulmonary 
murmur  to  a  regurgitation  through  the  mitral  valve  into 
the  left  auricle,  reaching  the  ear  by  the  auricular  appen- 
dix. Hence  the  fact  that  the  murmur  attains  its  greatest 
intensity  not    in    the  '  pulmonary    area    but    to  its  left. 

Russell's  theory  ascribes  the  pulmonary  murmui  to 
pressure  of  a  distended  auricle  on  the  artery. 

Certain  systolic  murmurs  at  the  apex,  associated  with 
anaemia  and  neuroses,  but  unaccompanied  by  valve 
lesions,  Sansom  ascribes  to  an  actual  mitral  regurgita- 

*  It  will  be  remembered,  as  stated  on  p.  128,  that  Sansom  ascribes 
murmurs  to  vibrations  in  solids  rather  than  in  fluids  as  commonly 
accepted.  To  make  the  statements  quoted  accord  with  such  view 
we  have  only  to  suppose  that  the  vibrations  described  are  communi- 
cated to  the  blood  stream  and  conducted  thence  to  the  ear. 


VASCULAR   MURMURS.  141 

tion,  the  result  of  weakness  of  the  muscles  concerned  in 
closure  of  the  mitral  orifice.  Other  explanations  than 
these  are  assigned  by  various  authors,  for  information  as 
to  which  the  student  is  referred  to  Sansom's  recent 
work  on  "  Diseases  of  the  Heart  and  Thoracic  Aorta."  I 
will  only  add  that  Balfour,  for  one,  holds  that  the  pulmo- 
nary murmur,  is  not  an  arterial  but  an  auricular  murmur. 


VASCULAR   MURMURS. 

In  the  examination  of  arteries  the  stethoscope  is  ap- 
plied— for  the  carotid,  at  the  intersection  of  the  steino- 
cleido-mastoid  muscle  into  the  clavicle  and  sternum,  and 
carried  upward  along  the  anterior  edge  of  the  muscle ; 
for  the  subclavian,  behind  the  clavicular  insertion  of  the 
sterno-cleido-mastoid  muscle,  the  arm  being  dependent ; 
for  the  brachial,  on  the  inner  border  of  the  biceps  at 
the  bend  of  the  elbow,  with  the  arm  partially  flexed, 
and  for  the  crural,  in  the  popliteal  space.  Care  should 
be  taken  to  apply  the  stethoscope  very  lightly,  as 
pressure  itself  will  engender  a  sound  called  the  acoustic 
pressure  murmur.  This  may  be  made  self  audible  at 
almost  any  time  with  sufficiently  quiet  surroundings  by 
pressing  upon  the  artery  in  front  of  the  ear. 

Normal  Arterial  Murmurs. — Considering  the 
apparent  simplicity  of  the  matter,  there  is  a  singular 
discrepancy  in  the  statements  concerning  the  so-called 
normal  arterial  murmurs.  I  am  inclined  to  agree  with 
W.  Russell,  who  says  no  murmur  originates  in  the 
great  vessels  of  the  neck  in  health,  unless  it  be  as  the 


142  PHYSICAL   DIAGNOSIS. 

result  of  undue  pressure  with  the  stethoscope.  On  the 
other  hand,  there  can  be  no  doubt  that  two  sounds  are 
commonly  heard  on  such  auscultation.  My  own  obser- 
vations go  to  show  the  following :  If  a  stethoscope  be 
thus  lightly  placed  over  the  caiotid  or  subclavian  arte- 
ries, so  as  not  to  compress  the  vessels,  two  sounds  are 
heard  with  each  movement  of  the  heart — one  corre- 
sponding to  the  systole  of  the  ventricles  and  the  expan- 
sion of  the  arteries,  the  other  to  the  diastole  of  the  heart 
and  the  contracting  recoil  of  the  arteries.  The  first  is 
shorter  and  fainter  and  is  the  first  sound  propagated 
from  its  seat  of  production,  the  auriculo-ventricular 
valves.  The  longer  and  louder  is  the  second  or  aortic 
heart-sound,  conducted  from  the  site  of  its  production, 
the  aortic  valves.  The  latter  sound  is  occasionally 
heard  in  the  abdominal  aorta,  more  rarely  in  the 
brachial  and  femoral.  The  fainter  sound  is  not  con- 
ducted so  far. 

Abnormal  Arterial  Murmurs. — Abnormal  sounds 
are  conducted  into  the  arteries  in  valvular  disease  of  the 
heart,  particularly  aortic  disease,  both  obstructive  and 
regurgitant,  and  rarely  also  in  mitral  disease.  The 
systolic  murmur  of  aortic  stenosis  is  always  conducted 
at  least  into  the  great  vessels  of  the  neck. 

Finally,  murmurs  may  arise  in  the  larger  arteries 
themselves  from  any  causes  which  produce  a  change  in 
the  diameter  of  the  vessel,  such  as  aneurismal  dilatation, 
congenital  narrowing,  or  narrowing  due  to  thrombi  or 
to  compression  from  any  cause,  such  as  adhesions,  con- 
traction   of   cicatricial    tissue,   morbid    growths    or    in- 


VASCULAR   MURMURS.  1 43 

flammatory  infiltration,  or  the  pregnant  uterus.  Thu 
a  murmur  may  occur  in  a  branch  of  the  pulmonary 
artery  from  pressure  by  a  tubercular  deposit  or  pneu- 
monic infiltration  or  enlarged  bronchial  gland,  and  a 
murmur  may  even  be  produced  in  the  subclavian  artery 
by  a  tubercular  deposit  at  the  left  apex.  A  murmur  in 
a  branch  of  the  pulmonary  artery  from  such  cause  is 
intensified  during  expiration,  while  a  murmur  in  the 
left  subclavian  from  the  same  cause  is  said  to  be  intensi- 
fied by  holding  the  breath  at  inspiration.  Thyroid 
tumors  in  the  neck  also  produce  arterial  murmurs  by 
pressure. 

Sounds  also  arise  in  the  larger  arteries  as  the  result  of 
change  of  pressure.  Such  is  Traube's  sound  produced 
in  aortic  regurgitation.  This  is  usually  a  double  sound, 
of  which  the  first  element  is  due  to  the  rapid  distension 
of  the  artery  by  a  blood-wave  which  throws  its  walls 
into  vibration.  A  second  sound  occurs  with  the  cessa- 
tion of  the  pressure. 

The  placental  murmur  is  a  mixed  venous  and 
arterial  murmur. 

Venous  Murmurs. — These  are  distinguished  from 
arterial  murmurs  by  their  continuousness  as  contrasted 
with  the  intermittent  arterial  murmur.  An  acoustic 
pressure  murmur  may  be  produced  in  any  vein  which  is 
large  enough,  as  the  jugular  and  femoral,  by  pressing 
slightly  upon  it  with  the  stethoscope,  without,  however, 
pressing  so  hard  as  to  obliterate  the  blood  current. 

Murmurs  independent  of  such  pressure  are  sometimes 
heard  in  these  large  veins,  including  the  femoral,  from 


144  PHYSICAL    DL4.GNOSIS. 

tricuspid  regurgitation,  but  the  principal  pathological 
venous  murmur  is  the  venous  hum  or  bruit  de  diable. 
It  is  compared  to  the  sound  heard  on  placing  a  sea-shell 
of  moderately  large  size  against  the  ear.  It  is  frequently 
heard  in  chlorotic  females  over  the  bulb  or  dilatation  of 
the  internal  jugular  vein;  also  sometimes  in  the  large 
intrathoracic  trunks,  the  superior  cava,  and  the  innom- 
inata.  It  is  best  heard  on  the  right  side  by  turning  the 
head  as  far  as  possible  to  the  left  and  then  placing  the 
stethoscope  above  the  right  clavicle  behind  the  sterno- 
cleido-mastoid  muscle,  or  over  the  sterno-clavicular 
articulation,  by  which  an  artificial  murmur  from  pressure 
is  avoided.  It  is  a  continuous  soft  murmur  resembling 
the  humming  of  a  top,  and  by  its  continuousness  can 
be  readily  distinguished  from  an  intermittent  arterial 
murmur.  This  murmur  cannot  be  regarded  as  ahvays 
abnormal,  since  it  is  often  heard  in  healthy  individuals. 
Thus  Winterich  found  it  in  So  per  cent,  of  the  Bavarian 
cuirassiers  whom  he  examined.  It  is  much  more  fre- 
quent in  women  than  men  in  the  proportion  of  7  to  i, 
according  to  Aran.  Extreme  loudness  may  be  regarded 
as  an  indication  of  abnormality.  Its  presence  may 
especially  be  regarded  as  corroborative. 


THE  SPHYGMOGRAPH   IN   DIAGNOSIS. 

Whatever  the  diagnostic  value  of  the  sphygmographic 
tracing  in  valvular  heart  disease,  and  it  is  sometimes  con- 
siderable, no  study  of  a  case  of  such  disease  is  complete 
without  it.     While  the  original  sphygmograph  of  Marey 


THE    SPHYGMOGRAPH    IN   DIAGNOSIS.  1 45 

probably  furnishes  a  better  tracing  than  any  of  the 
modern  instruments,  the  latter  have  the  advantage  of 
cheapness.  That  of  Dudgeon  is  the  most  popular  at 
the  present  day,  especially  Richardson's  modification 
with  sphygmometric  attachment.  Directions  for  its  use 
and  the  preparation  of  suitable  paper  always  accompany 
the  instrument.  Space  need  not  therefore  be  occupied 
by  them.  By  means  of  the  sphygmometer  varying 
degrees  of  tension  may  be  measured  before  the  tracing 
is  made.  In  the  pulse  of  low  tension  the  maximum 
movement  of  the  lever  is  attained  with  slight  degrees  of 
pressure,  and  small  increase  of  the  same  tends  to  extin- 
guish the  tracing.  In  pulses  of  high  tension  the  maxi- 
mum excursion  of  the  lever  is  brought  only  by  rather 
strong  pressure,  and  the  strongest  pressure  will  not 
extinguish  the  tracing. 

The  Normal  Pulse  Tracing  — This  is  shown  in 
the  drawing  on  p.  146.  It  consists,  first,  of  a  vertical  or 
almost  vertical  up-stroke,  a  b.2.  sudden  oblique  fall,  soon 
interrupted  by  a  notch,  c,  followed  by  a  short  rise  to  d, 
another  fall,  a  second  notch,  e,  and  another  rise  to  /, 
followed  by  an  undulating  fall  to  the  base  line  of  the 
sphygmogram.  The  anacrotic  or  up-stroke,  ox perc2ission 
stroke,  as  it  is  also  called,  is  the  effect  of  the  sudden 
dilatation  *  of  the  artery  upon  the  lever,  which,  having 

*  It  is  held  by  Broadbent  that  no  actual  increase  of  the  lumen  of 
the  artery  takes  place  in  the  formation  of  the  pulse,  but  that  with 
the  filling  of  the  vessel  it  simply  changes  from  the  oval  to  the 
circular  shape.  This  seems,  however,  to  be  an  error,  as  an  actual 
increase  in  diameter  is  easily  demonstrable  by  suitable  instruments. 


T46 


PHYSICAL   DL4GN0SIS. 


reached  its  maximum  height,  falls  to  rise  again  and  form 
"the  ?iO-C'2i\\e.d.  tidal  OT  p7-e dicrotic  loave,  c  d  e.  This  wave 
is  still  a  part  of  the  effect  of  the  distending  force  of  the 
vessel  on  the  lever,  which  through  its  inertia  is  carried 
too  high,  then  falls,  and  is  again  caught  by  the  still 
dilating  vessel  and  carried  to  d.  The  vessel  now  begins 
to  collapse  and  the  lever  to  fall  with  it,  but  soon  rises 
again  to  form  the  curve,  ^/rt:,  called  the  normal  dici-oUc 


Fig.  27. — Normal  Sphygmogram  Enlarged. 

1^.  Percussion  up-stroke.  a  b  c.  Percussion  wave,  c  d  e.  Tidal  rr  predi- 
crotic  wave,  ef  a.  Dicrotic  wave,  d  e  f.  Aortic  notch,  /a.  Diastolic 
notch. —  Sanso7!z.) 


wave,  while  the  notch  immediately  before  it  is  the  aortic 
or  predicrotic  notch.  The  dicrotic  wave  is  the  result  of 
a  second  rise  of  the  vessel  wall  due  to  the  elastic  recoil 
of  the  over-dilated  aorta  on  the  contained  blood,  which, 
being  prevented  from  going  backward  by  the  closed 
aortic  valve,  moves  forward,  producing  the  dicrotic 
wave.  The  second  sound  of  the  heart  is  found  to  coin- 
cide exactly  with  the  predicrotic  notch,  ^<?/.     Subse- 


THE    SPHYGMOGRAPH    IN    DIAGNOSIS.  1 47 

quent  slight  waves,  which  may  or  may  not  be  present, 
are  ascribed  to  vibrations  due  to  the  elasticity  of  the 
vessel.  The  further  the  vessel  is  tested  from  the  heart, 
the  greater  is  the  distance  as  a  rule  between  the  dicrotic 
and  the  predicrotic  wave.  The  pulse  wave  reaches  the 
more  distant  parts  of  the  aiteiial  system  at  successive 
intervals. 

The  effect  of  increased  pressure  of  the  button  of  the 
sphygmograph  on  the  artery  is  to  shorten  the  first  or 
percussion  wave,  and  to  render  the  dicrotic  wave  more 
distinct,  also  the  smaller  vibrations  in  the  down  stroke. 
Apart  from  this,  the  altitude  of  the  percussion  stroke 
depends  upon  the  quantity  of  blood  thrown  from  the 
ventricle,  but  is  more  or  less  peculiar  to  ihe  individual, 
and  its  smallness  in  one  as  compared  with  another  does 
not  necessarily  imply  that  such  person  has  an  abnorm- 
ality in  his  circulatory  apparatus,  while  the  tracings, 
even  in  the  two  radials,  of  a  person  perfectly  healthy 
may  not  be  identical,  because  of  difficulty  in  applying 
the  instrument  in  precisely  the  same  manner,  or  of  ana- 
tomical differences  on  the  two  sides,  making  such  appli- 
cation impossible.  The  special  features,  of  the  sphygmo- 
gram  in  different  cardiac  affections  will  be  given  in 
connection  with  them. 

Two  modifications  of  the  normal  sphygmogram  re- 
quire, however,  special  allusion,  since  they  are  the  con- 
sequences of  a  variety  of  morbid  states.  They  are  the 
sphygmogram  of  Jiigh  arterial  tension,  or,  as  Dr.  San- 
som  prefers  to  call  it,  prolonged  arterial  tension,  and  low 
arterial  tension. 


I4o  Pm^-SICAL   DLA. GNOSIS. 

Prolonged  arterial  tension  is  a  condition  in 
which  the  pressure  in  the  interior  of  a  blood-vessel  is 
unduly  prolonged.  The  effect  of  the  tracing  is,  in  a 
v\'ord,  to  broaden  the  top  of  the  primary  curve,  as  shown 
in  the  accompanying  sphygmogram. 


Fig.  28. — Sphygmogram  Showing  Prolonged  Arterial  Tension. — {Sansom.) 

In  some  instances  the  ascending  limb  of  the  sphyg- 
mogiam  is  broken  into  two,  as  shov\n  in  Fig.  28,  the 
attainment  of  the  maximum  altitude  being  delayed  by 
the  intravascular  resistance.     The  dicrotic  wave  is  small. 

Such  a  sphygmogram  is  called  anaci'otic,  and  the 
pulse  producing  it  an  anacrotic  pulse. 


Fig.  29. — Anacrotic  Pulse-cur\'E3  from  the  Radial  Artery. — 
{Landozs  and  Stirling:) 


The  pulse  of  prolonged  arterial  tension  is  produced 
by  any  cause  of  resistance  to  the  motion  of  the  blood 
through  the  capillaries  and  arterioles,  and  such  causes 
are  numerous.     Chronic  renal   disease,  especially  inter- 


THE    SPHYGMOGRAPH    IN    DIAGNOSIS.  1 49 

stitial  nephritis,  is  one  of  them;  so  are  gout,  lead 
poisoning,  constipation,  atheroma  of  the  arterial  walls, 
and  even  anaemia.  The  anacrotic  puLe  is  also  produced 
in  aortic  stenosis,  where  it  has  diagnostic  value. 

Low  arterial  tension  is  the  reverse  of  i)rolonged 
arterial  tension.  Instead  of  the  filled  state  of  the 
vessel  being  maintained,  the  fulness  is  of  short  duration 
and  the  wall  drops  away  at  once.      Such  a  pulse  is  easily 


Fig.  30. — Tracing  ok  Pulse  of  Aortic  Regurgitation. — {Striimpell.') 

obliterated  by  piessure,  while  tl  e  pulse  of  high  tension 
is  difificult  10  obliterate.  As  1o  the  sphygmographic 
tracing,  the  up-stroke  is  vertical,  the  apex  angle  is  acute, 
the  tidal  wave  is  insignificant,  while  the  dicrotic  wave 
is  the  most  conspicuous  feature  of  the  tracing.  Fig.  30 
furnishes  a  marked  example  of  such  a  tracing,  in  which 
the  first  wave  of  the  down-stroke  is  the  dicrotic  wave, 
the  tidal  wave  being  wanting. 

Dicrotism  in  pulse  of  low  tension  may  even  exceed 


150  PHYSICAL    DLA.GNOSIS. 

tijat  indicated  in  the  sphygmogram.  Thus  it  may 
spring  from  the  level  of  the  base  line,  when  it  is  called 
full  dicrotic,  or  it  may  start  from  below  the  base  hne, 
when  it  is  called  hyperdic7-otic,  or  even  be  in  the 
ascending  line  of  the  succeeding  trace,  when  it  is  called 
liifluocrotic. 

The  pulse  of  low  tension  may  be  pioduced  aitificially 
by  the  administration  of  nitroglyceiin  or  the  applica- 
tion of  heat  to  the  surface  of  the  body,  as  by  the  warm 
bath,  the  conditions  being  suddenness   of    cardiac    im- 


FlG.    31. — TRACIN'li    FROM    CaPE    OF    PROLONGED    ARTERIAL   TENSION,  SHOWING 

Dicrotic  Wave. — [Sansonz.) 


pulse  and  absence  of  resistance  to  the  onward  move- 
ment of  the  blood;  it  is  very  characteristic  of  aortic 
regurgitation,  of  collapsed  conditions  such  as  are  the 
result  of  depressing  emotions  and  colliquative  discharges 
like  diarrhoea  and  copious  diuresis.  It  is  also  found 
in  fever,  of  which  the  dicrotic  pulse  is  more  or  less 
characteristic.  Abnormal  dicrotism  is  not,  however, 
confined  to  low  tension.  It  varies  within  the  limits  of 
health,  and  occurs  at  times  in  connection  with  high 
tension,  as  shown  by  Roi  and  Adami,  where  there  is  a 
sharp,  sudden  systole  of  the  ventricle,  leading  to  a  cor- 
responding sharp  and  energetic  rebound  or  reactionary 
wave,  as  shown  in  Fig.  31. 


THE    SPHYGMOGRAPH    IN   DIAGNOSIS,  15  I 

Erroneous  interpretations  of  such  dicrotism  may  be 
avoided  by  increasing  the  pressure  of  the  sphygmograph, 
when,  if  the  tension  is  low,  the  tracing  is  obhterated, 


Fig.  32. — Bigeminal  PuLSt:. —  {After  Byroin  Bramwell.) 

while  if  it  is  high  the  first  wave  becomes  broadened  and 
the  dicrotism  less. 

Irregularity  of  pulse  as  recognized  by  the  finger  may 
be  recorded  by  the  sphygmograph  and  thus  better  sub- 


FiG.  33. — Trigeminal  Pulse. — {From  Hutchison,  and  Rainy.) 

mitted  to  analysis.  Such  a  record  is  the  tracing  of  the 
pulsus  bigeminus  appended,  in  which  the  beats  occur  in 
regular  sequence — two  beats  and  a  pause.  Three  beats 
and  a  pause  give  the  pulsus  trigeminus  shown  in  Fig.  33. 


152  PHYSICAL   DIAGNOSIS. 

THE  CARDIOGRAPH   IN   DIAGNOSIS. 

The  cardiograph  does  not  furnish  as  valuable  assistance 
to  diagnosis  as  the  sphygmograph,  chiefly  because  of 
the  difficulty  in  getting  typical  tracings.  Tracings  are 
usually  taken  from  the  site  of  the  apex,  although  they 
may  also  be  obtained  from  the  various  chambers  of  the 
heart  in  a  large  animal  like  the  horse  by  introducing  an 
elastic  bag  and  attached  tube  into  the  right  cavities 
through  an  opening  in  the  jugular  vein,  and  into  the 
left  cavities  thiough  an  incision  in  the  carotid  artery,  con- 
necting each  bag  and  tube  with  a  jMarey's  tambour  and 
thence  to  a  revolving  drum.  Any  pulsating  part  of  the 
heait,  as  the  left  auricle,  may  be  brought  into  connection 
with  the  cardiograph  and  a  tracing  therefrom  secured, 
while  without  an  appreciable  impulse  a  tracing  is  impos- 
sible even  at  the  apex.  Appended  are  a  number  of 
noimal  apex  tracings  in  which  a  represents  the  auricular 
systole,-  the  ascent,  a  d  the  contraction  of  the  ventricle, 
d  e  f  the  continued  systole,  k  the  effect  of  the  first 
sudden  entrance  of  blood  into  the  ventricles,  /  the 
gradual  ascent  from  the  gradually  increasing  flow  of 
blood  into  the  ventricles  during  diastole,  and  a  d 
again  the  systole  of  the  ventricles.  The  notch,  d  e  f, 
is  constant,  the  height  of  the  primary  elevation  being 
exaggerated  by  the  velocity  of  the  needle  in  the  instru- 
ment employed. 

Considerable  variation  takes  place  in  the  apex  cardi- 
ogram as  the  result  of  varying  pressure,  while  partial 
and  even  complete  inversion  of  the  tracing  may  occur, 


THE    CARDIOGRAPH    IN   DIAGNOSIS.  153 

whence  another  source  of  difficulty  in  the  way  of  cUni- 
cal  availability  of  the  cardiogaph,  for  it  cannot  be 
relied  upon  to  express  accurately  the  direction  of  the 
different  events  of  the  cardiac  action. 

The  position  of  the  sounds  of  the  heart  in  relation  to 
points  in  the  apex  trace  have,  however,  been  deter- 
mined with  some  approach  to  accuracy.  Thus  the  first 
sound,  as  determined  by  its  muscular  element,  is  re- 
garded as  commencing  with  the  first  ascent  of  the  lever, 


Fig.  34. — Normal  Cardiac  Apex  Tracing. — {Galabin.) 

and  continuing  until  the  termination  of  the  rounded 
shoulder,/,  at  which  the  muscle  of  the  ventricular  wall 
relaxes.  So  far  as  concerns  the  factor  of  valvular  ten- 
sion, the  position  of  the  first  sound  must  be  assigned  to 
a  point  near  the  summit  of  the  up-stroke,  where  the 
sudden  contraction  of  the  papilla?-)'  muscles  begins,  con- 
tiuning  to  the  beginning  of  the  rounded  shoulder,  /, 
where  this  contraction  ceases,  the  muscle  of  the  ven- 
tricular wall  remaining  still  contracted. 

The    second    sound  occurs  somewhere    between   the 


154  PHYSICAL   DIAGNOSIS. 

shoulder,/,  and  the  lower  extremity  of  the  descending 
line  succeeding  it. 

In  the  apex  cardiogram  of  the  normal  heart-beat  the 
systole  a  d  is  decidedly  shorter  than  the  diastole  k  a, 
occupying  two-fifths  as  compared  with  three-fifths.  As 
the  rate  of  the  pulse  increases  the  diastohc  interval 
shortens,  until  the  systole  and  diastole  become  equal, 
although  precise  measurement  of  the  absolute  deviations 
of  these  phases  by  the  cardiograph  is  as  yet  impossible. 
Their  relative  duration  may,  however,  be  thus  meas- 
ured, as  may  also  be  the  fo:ce  of  the  ventricular  con- 
traction by  the  height  of  the  up-stroke.  The  breadth 
of  the  summit  of  the  trace  measures  the  duration  of 
the  systole  and  increases  with  hypertrophy  of  the  ven- 
tricles. 

In  abnormal  states  the  diastolic  portion  of  the 
tracing  is  (i)  relatively  diminished  or  (2)  relatively 
increased. 

1.  It  is  relatively  diminished — 
(«.)    In  hypertrophy. 

(J).')  Where,  in  addition  to  hypertroph}',  conditions  exist 
in  which  the  ventricle  becomes  too  rapidly  filled. 
This  occurs  in  aortic  regurgitation  and  in  mitral 
regurgitation  when  there  is  hypertiophy  of  the  left 
auricle;  also  in  the  two  conditions  combined. 

2.  The  diastolic  portion  of  the  tracing  is  relatively 
increased — 

(a.)  When  the  heart's  action  becomes  slow,  the  differ- 
ence between  a  frequent  pulse  and  a  slow  pulse 
being  chiefly  in  the  length  of  the  diastole. 


THE    CARDIOGRAPH    IN   DIAGNOSIS.  155 

(^.)  Dilatation  of  the  left  ventricle,  the  conditions  being 
the  opposite  of  those  of  hypertrophy.  Herein  we 
have  one  of  the  most  valuable  diagnostic  uses  of 
the  cardiograph.  It  is  not  always  easy  by  other 
clinical  means  to  inform  ourselves  when  this 
serious  change  has  taken  place  which  involves  a 
loss  of  compensations.  The  cardiograph  enables 
us  to  do  so. 

(<r.)  In  mitral  stenosis,  where  the  diastolic  interval  is 
often  markedly  pronounced,  while  at  other  times  it 
is  found  to  vary  greatly  in  duration,  two  systoles 
occurring  without  an  appreciable  diastolic  interval, 
while  between  two  others  there  may  be  a  prolonged 
interval.  Much  more  characteristic,  according  to 
Sansom,  who  has  devoted  much  study  to  this  sub- 
ject, are  the  number  of  vibrations  in  the  diastolic 
part  of  the  trace.  "  In  fact,"  says  Sansom,  *  "  the 
vibrations  which  are  heard  by  the  ear  as  murmurs, 
or  felt  by  the  finger  as  thrills,  may  be  written  on 
the  smoked  paper  by  the  needle  of  the  cardio- 
graph." Many  other  clinical  facts  of  interest 
and  importance  may  be  studied  to  advantage  by 
the  cardiograph,  but  I  must  refer  the  student  to  the 
■   larger  works  for  their  consideration. 


*  Lettsomian  Lectures  on  "  Valvular  Diseasesof  the  Heart,"  i{ 


156  PITi'SICAL   DL4GN0SIS. 

PHYSICAL  SIGNS  OF  THE  DIFFERENT 
FORMS  OF  VALVULAR  DISEASE. 

MITRAL  INSUFFICIENCY. 

This  is  the  most  frequent  of  the  uncombined  forms  of 
valvular  disease.  The  valve  leaks,  the  blood  flows  back- 
ward during  systole  from  the  left  ventricle  to  the  left 
auricle  and  distends  it.  The  auricle  first  attempting  to 
resist  the  backward  flow  hypertrophies  slightly,  but 
eventually  dilates,  and  the  blood  is  crowded  backward 
into  the  lungs,  which  become  engorged.  The  right 
ventricle,  in  its  efforts  to  push  the  blood  through  the 
engorged  lungs,  hypertrophies,  and  the  pulmonary 
factor  of  the  second  sound  becomes  louder  and  sharply 
accentuated.  The  compensating  effect  of  the  hyper- 
trophied  right  ventricle  for  a -time  arrests  the  mischief. 
At  this  stage  may,  begin  the  hypertrophy  of  the  left 
ventricle,  which  in  all  cases  of  mitral  insufficiency  pre- 
sents itself  sooner  or  later,  although  at  first  the  double 
outlet  for  the  blood  from  the  ventricle  would  seem  to 
demand  less  strength  of  the  left  ventricle.  The  right 
ventricle,  however,  in  its  hypertrophied  state,  delivers 
more  blood  to  the  left  ventricle,  which  demands  more 
power  to  drive  it  on,  hypertrophy  results,  and  thus 
compensation  is  a  while  longer  maintained.  Or  it  may 
be  that  hypertrophy  of  the  left  ventricle  begins  with 
the  distension  and  hypertrophy  of  the  left  auricle. 
Sooner  or  fater  the  right  ventricle  dilates,  the  tricuspid 
valve  becomes  relatively  insufficient,  the  blood  regurgi- 


MITRAL   INSUFFICIENCY.  157 

tates  into  the  right  aurticle,  and  thence  into  the  great 
veins  of  the  neck.  The  valves  of  these  ultimately 
yield,  the  jugular  pulse  appears,  and  the  general  venous 
system  is  engorged.  In  this  engorgement  the  liver, 
stomach  and  kidneys  share.  Then  comes  transuda- 
tion, dropsy,  albuminuria.  Among  the  latter  pheno- 
mena in  extreme  cases  are  an  enlarged,  tender,  and 
pulsating  liver,  a  symptom  which  is  pathognomonic  of 
tricuspid  regurgitation,  but  a  liver  lifted  by  some  pul- 
sating agency  behind  it  must  not  be  confounded  with 
the  true  pulsating  liver.  More  frequently  the  liver  is 
visibly  enlarged  and  tender  without  visible  pulsation. 
Such  enlargement  disappears  in  part  after  death,  and  is 
not  noticeable  at  the  necropsy. 

Inspection  discovers  the  apex-beat  to  the  left  of  its 
normal  position  and  perhaps  a  little  lower  down.  It 
may  be  in  the  line  of  the  nipple,  rarely  beyond  it,  and 
more  forcible  and  diffuse  than  in  health.  The  outward 
dislocation  of  the  apex-beat  is  due  to  the  enlargement 
of  the  two  ventricles.  An  auricular  pulse  may  be 
present  to  the  left  of  the  pulmonic  area  in  the  2d 
interspace,  or  systolic  and  passive  for  the  auricle.  A  bulg- 
ing prsecordium  may  be  looked  for  in  young  persons, 
and  in  advanced  stages  also  a  jugular  pulse. 

Palpation  more  precisely  determines  the  position  of 
the  apex-beat,  which  is  found  more  forcible  than  normal. 
It  may  detect  a  pulsation  near  the  ensiform  cartilage 
caused  by  the  systole  of  the  enlarged  right  ventricle. 
The  apex  is  also  displaced  to  the  left.     Sometimes  an 


158  PHYSICAL   DLA. GNOSIS. 

intermittent  systolic  thrill  is  felt  in  the  4th  interspace  in 
the  left  mammillary  line. 

The  radial  pulse  in  the  early  stages  is  comparatively 
unaltered.  Later  it  becomes  frequent  and  irregular  in 
volume.  Appended,  Fig.  35,  is  a  sphygmogram  of  the 
pulse  in  advanced  mitral  insufficiency.  It  is  of  the 
type  of  the  pulsus  parvus  i7-regulaj-is. 

Percussion  discovers  enlargement  of  both  the  relative 
and  absolute  areas  of  dulness_.  upward  in  the  direction 
of  the  left  auricle,  downward  to  the  left  and  also  to  the 
right,  the  absolute  dulness  reaching  at  times  the  right 


Fig.  35. — Tracing  of  Pulse  of  Mitral  Insufficiency. — {Da  Costa.) 

border  of  the  sternum,  though  often  enlargement  in  this 
direction  is  not  demonstrable. 

Auscultation  recognizes  a  systolic  murmur  in  the 
mitral  area,  conducted  with  various  degree  of  loudness 
into  the  left  axilla  and  under  the  angle  of  the  scapula. 
This  direction  of  its  conduction  is  the  distinctive  feat- 
ure of  this  murmur.'  It  is  usually  soft,  but  occasionally 
rough,  more  rarely  musical.  It  is  also  sometimes  well 
heard  to  the  left  of  the  pulmonary  cartilage,  and  rarely 
over  the  entire  prsecordium.  Not  always  loud  enough 
to  be  easily  heard,  it  may  be  brought  out  by  exertion 
on  the  part  of  the  patient. 

The  second  sound  of  the  heart  is  sharply  accentuatea 


MITRAL   STENOSIS.  159 

at  the  pulmonary  interspace  until  the  tricuspid  valve 
fails,  when  the  accentuation  vanishes.  The  aortic  sec- 
ond sound  is  less  strong,  corresponding  with  the  less 
degree  of  hypertrophy  of  the  left  ventricle. 


MITRAL  STENOSIS. 

This  lesion  occurs  as  an  uncombined  or  simple  form 
of  valvular  disease  in  young  persons,  especially  women, 
but  is  very  much  more  commonly  combined  with 
regurgitation.  The  orifice  is  stenosed  and  the  blood  is 
restrained  from  passing  freely  into  the  left  ventricle. 
The  same  backward  effect  as  in  mitral  regurgitation  is 
produced  upon  the  left  auricle,  the  lungs,  the  right  ven- 
tricle, and  general  venous  circulation,  but  the  left 
ventricle  is  not  hypertrophied  in  simple  mitral  obstruc- 
tion, because  no  extra  muscular  effort  is  called  for, 
while  hypertrophy  of  the  left  auricle  is  one  of  the  most 
characteristic  signs  of  mitral  stenosis.  Theoretically, 
the  left  ventricle  should  even  atrophy,  but  the  absence 
of  the  enlargement  is  of  great  diagnostic  value. 

Inspection,  consistently  with  what  would  be  expected 
in  absence  of  hypertrophy  of  the  left  ventricle,  recog- 
nizes httle  or  no  displacement  of  the  apex.  If  there  is 
any  it  is  due  to  the  hypertrophy  of  the  right  ventricle, 
pushing  the  left  ventricle  outward.  Nor  is  the  apex- 
beat  increased  in  force.  A  left  auricular  impulse, 
presystolic,  may  be  noted  for  the  same  reason  as  in 
mitral  regurgitation,  as  may  also  a  jugular  impuse  and 
pulsating    liver.     A  bulging  prsecordium   may  be   pro- 


t6o 


PHYSICAL   DLA.GNOSIS. 


duced  by  the  enlarged  left  auricle  and  right  ventricle, 
but  is  not  often  seen. 

Palpation  discerns  that  the  apex-beat  is  without  undue 
force,  but  it  may  be  diffuse,  and  an  impulse  may  be  felt 
in  the  situation  of  the  apex  of  the  right  ventricle. 
The  most  marked  feature  of  palpation  when  present  is 
the  presystolic  thrill  at  the  apex.  It  is  similar  in  rhythm 
to  the  presystolic  murmur,  but  may  be  present  without 
it,  and  is  not  always  present. 

In    moderate    degrees    of    stenosis   the    pulse   is  not 


Fig.  36. — Tracings  of  Pulse  in  Mitral  Stenosis. 


altered  ;  in  high  degrees  it  is  very  small,  from  want  of 
left  ventricular  power;  also  irregular,  like  that  of 
mitral  regurgitations.  Two  tracings  from  cases  of 
mitral  stenosis  are  introduced  in  the  text. 

Percussion  recognizes  cardiac  enlargement  in  the 
direction  of  the  left  auricle  and  right  ventricle,  but  not 
of  the  left  ventricle. 

Auscultation  does  not  discover  a  murmur  in  every 
case  of  mitral  stenosis,  because  of  the  feebleness  of  the 
auricular     contraction,     especially    at    the     beginning. 


MITRAL   STENOSIS.  l6l 

Most  characteristic  is  the  abruptly  termmatrng  presysfo- 
lic  murmur  described  on  p.  131,  confined  for  the  most 
part  to  the  mitral  area,  though  it  may  be  conveyed 
upward,  and  it  is  even  heard  posteriorly,  though  rarely. 
Dr.  Sansom  places  it  rather  at  the  right  of  the  apex. 

Accentuation  of  the  second  sound  is  marked,  but 
confined  to  the  pulmonary  area,  because  there  is  no 
hypertrophy  of  the  left  ventricle.  The  second  sound 
may  also  be  duplicated,  because  of  the  want  of  syn- 
chronousness  in  the  closure  of  the  aortic  and  the  pul- 
monary valves.  Dr.  Sansom  regards  this  reduplication 
as  a  seeming  one  only  of  the  second  sound.  He  con- 
siders rather  that  the  normal  second  sound  is  followed 
by  another  sound  due  to  a  sudden  tension  of  the  mitral 
valve  itself,  producing  thus  a  seeming  reduplication. 
He  also  says  it  occurs  in  at  least  a  third  of  all  cases 
of  mitral  stenosis,  and  is  rare  in  other  cardiac  condi- 
tions. 

The  murmur  of  mitral  stenosis  is  sometimes  difficult 
to  distinguish  from  that  of  aortic  regurgitation,  but  in 
the  latter  there  is  enormous  hypertrophy  of  the  left  ven- 
tricle, which  is  wanting  in  mitral  stenosis.  The  time  of 
tricuspid  stenosis  is  identical  with  that  of  aortic  regurgi- 
tation, but  it  is  heard  in  a  different  part  of  the  prsecor- 
dium — in  the  epigastrium.  On  account  of  these  diffi- 
culties, while  the  presystolic  murmur  is  a  valuable  sign 
of  mitral  stenosis,  it  should  not  be  alone  rehed  upon  for 
diagnosis,  but  should  be  taken  in  connection  with  other 
signs.  Tricuspid  stenosis  may  be  associated  with  mitral 
stenosis,  or  insufficiency,  or  both,  though   it   is  a   rare 


1 62  PHYSICAL    DIAGNOSIS. 

lesion.      (See  p.  131  for  further  characterization  of  the 
presystolic  murmur;  also  Flint's  murmur.) 

Dr.  Sanson!  lays  great  stress  on  the  evidence  of  the 
cardiograph  in  the  diagnosis  of  mitral  stenosis,  which 
enables  one  to  judge  of  the  relative  length  of  systole 
and  diastole.  In  stenosis  the  inter\^al  between  the  sys- 
toles may  be  greatly  prolonged,  or  the  diastolic  intervals 
vary  greatly  in  duration.  In  mitral  regurgitation,  on 
the  other  hand,  a  short  interval  only  separates  the 
systoles. 

MITRAL   INSUFFICIENCY  AND   STENOSIS. 

More  common  than  mitral  stenosis  as  an  uncombined 
lesion,  about  twice  as  often,  according  to  Frederick  J. 
Smith's  analyses,  is  stenosis  associated  with  insufficiency, 
producing  the  double  mitral  murmur,  sometimes  with 
difficulty  divisible  into  its  two  parts.  Extreme  irreg- 
ularity of  rhythm  •  and  pulse,  with  frequency  and 
smallness  of  the  latter,  conspicuous  thrill,  marked  right- 
sided  hypertrophy,  and  sharply  accentuated  pulmonic 
sound  are  characteristic. 

AORTIC  STENOSIS. 

This,  as  a  simple,  uncomplicated  lesion,  is  the  most 
infrequent  form  of  valvular  disease.  When  uncombined 
with  regurgitation  it  is  the  least  dangerous.  The  aortic 
orifice  is  narrowed  and  prevents  the  free  discharge  of 
blood  from  the  left  ventricle  into  the  aorta.  The  ven 
tricle  attempts  to  overcome  this,  and  its  walls  hyper- 


AORTIC    STENOSIS.  163 

trophy  in  proportion  to  the  degree  of  lesistance,  and 
often  for  a  long  time  compensate  for  the  obstruction — 
until  dilatation  occurs,  when  the  danger  really  begins. 
Dizziness  is  a  frequent  symptom;  there  are  often  heard 
noises  in  the  ears,  the  patient  is  pale  and  subject  to 
fainting  and  cramps  in  the  muscles. 

Inspection  and  palpation  recognize  a  forcible  apex- 
beat  beyond  the  qormal  situation  and  at  varying  dis- 
tances according  to  the  degree  of  hypertrophy,  while 
palpation  adds  occasionally  a  purring  basic  thrill  with 
each  beat  of  the  heart,  more  especially  when  dilated 
hypertrophy  is  established,  A  bulging  of  the  prsecor- 
dium  is  also  present. 


Fig.  37. — Pulse  Tracing  of  Aortic  Stenosis. 

The  pulse  is  the  pulsus  tardus,  parvus,  rarus,  slow  in 
reaching  its  maximum  volume,  which  is  small.  It  is 
frequent  but  regular,  contrasting  in  the  latter  respect 
with  the  pulse  of  mitral  disease.  Fig,  37  is  a  sphyg- 
mogram. 

Percussion  elicits  dulness  downward  and  laterally 
toward  the  left,  since,  as  a  rule,  the  enlargement  is  con- 
fined to  the  left  ventricle.  There  may,  however,  be 
enlargement  upward  to  the  left  of  the  sternum. 

Ausctiltation  discloses  a  systolic  basic  murmur,  loudest 
^t  the  aortic  area — 2d  interspace  at  the   right  of  the 


164  PHYSICAL   DIAGNOSIS. 

sternum — which  is  conducted  distinctly  into  the  caro- 
tids, and  even  sometimes  along  the  course  of  the  aorta 
behind  and  to  the  left  of  the  vertebral  column,  into  the 
pophteals  and  dorsal  arteries  of  the  feet.  It  is  not,  how- 
ever, confined  to  this  area,  but  may  be  heard  over  the 
entire  praecordium.  It  is  usually  rough,  but  may  be 
soft  and  musical.  It  is  made  louder  by  exercise.  The 
aortic  factor  of  the  second  sound  is  weak  if  the  con- 
striction be  at  all  decided,  because  of  the  feeble  recoil, 
a  necessary  result  of  the  small  amount  of  blood  in  the 
vessel.  The  first  sound  is  normal  and  somewhat  louder 
and  more  prolonged  than  natural,  because  of  the  power- 
ful contraction  of  the  left  ventricle. 

Roughness  of  the  aorta  due  to  atheroma,  dilatation, 
or  narrowing  of  the  vessels  by  pressure  or  otherwise, 
may  also  cause  a  systolic  murmur,  and  so  may  roughness 
within  the  ventricle  in  the  course  of  the  outgoing 
column  of  blood ;  but  these  causes  have  generally  a  less 
positive  effect  upon  the  substance  of  the  heart.  It  is 
important,  therefore,  to  remember  that  an  aortic  systolic 
murmur  by  no  mea?is  always  mdicates  aortic  stenosis.  In 
like  manner  ansemic  or  hsemic  murmurs,  which  are 
always  systohc  and  for  the  most  part  basic,  may  simulate 
aortic  systolic  murmurs,  but  these  occur  in  young, 
dehcate  persons,  of  both  sexes,  and  are  often  inter- 
mittent and  without  other  effect  on  the  circulation. 
There  may  be  roughness,  too,  in  the  pulmonarj'  artery, 
which  can  be  localized  to  the  left  of  the  sternum. 


AORTIC   INSUFFICIENCY.  1 65 

AORTIC   INSUFFICIENCY. 

The  most  serious  and  irremediable  of  the  valvular  dis- 
eases of  the  heart  commonly  met  with;  more  frequently 
associated  with  aortic  stenosis,  it  is  still  not  rare  uncom- 
bined.  It  is  the  lesion  most  frequently  followed  by  sud- 
den death.  The  aortic  valves  are  incompetent  and  the 
blood  flows  backward  into  the  lelt  ventricle  during 
diastole.  The  ventricle,  seeking  to  restore  the  balance, 
redoubles  its  energy,  hypertrophies.  The  blood  is  thus 
driven  into  the  aorta  with  great  force,  swelling  the  arteries 
to  extreme  fulness,  which,  however,  falls  away  promptly, 
because  of  the  backward  flow  into  the  ventricle  at  the 
same  time  with  the  forward  movement  into  arteries  and 
capillaries.  This  sudden  falling  away  of  the  pulse, 
fiom  extreme  distension  to  collapse,  is  very  characteristic 
of  this  form  of  valvular  disease,  and  is  called  the  "  trip- 
hammer "  or  "  water-hammer  pulse,'"  also  Corrigan 
pulse.  It  may  even  be  visible  to  the  casual  observer  in 
the  exposed  arteries,  such  as  the  carotid,  temporal,  and 
radial,  while  the  aoric  beat,  ordinarily  beyond  reach 
in  the  suprasternal  notch,  may  sometimes  be  felt  in  this 
situation.  The  abrupt  jerking  impulse  with  sudden 
recoil  is  easily  recognized  by  the  finger,  which,  how- 
ever, fails  to  find  the  pulse  as  strong  and  hard  as  would 
be  expected  from  the  appearance.  On  the  other  hand, 
it  is  soft  and  receding — a  pulse  of  low  tension.  A 
tracing  of  this  pulse  is  found  in  Fig.  38.  It  is  the 
typical  pulsus  celer  et  altus. 

The   tremendous  systole  of  the   ventricle  may  ulti- 


1 66  PHYSICAL    DIAGNOSIS. 

mately  force  the  mitral  valve  to  yield,  axid  compensa- 
tion to  be  gradually  lost  pari  passu  with  a  growing 
dilatation.  To  this  succeed  the  phenomena  of  relative 
mitral  insufficiency,  regurgitation,  and  h}'pertrophy  of 
the  right  ventricle.  The  latter  comes  for  a  time  to  the 
rescue,  but  weakens  with  the  giving  away  of  the  tricus- 
pid valve. 

Inspection  often  discerns  the  prcecordium  prominent, 


Fig.  38. — Tracing  of  Pulse  of  Aortic  Regurgitation. — {Strihnpell.') 

with  the  apex-beat  lowered  and  to  the  left,  and  the 
visible  pulsation  far  beyond  the  normal  situation  of  the 
apex,  all  confirmed  by  palpation,  to  which  is  also  evi- 
dent at  times  a  systolic  thrill  over  the  carotids  and 
subclavians,  and  sometimes  in  :he  aorta  at  the  supra- 
sternal notch.  A  capillary  pulse  is  also  sometimes 
demonstrable  in  the  skin  and  mucous  membrane.  This 
may  be  brought  out  by  pressing  the  end  of  the  finger- 
nail and  watching  the  pink  zonula;  or  in  the  line   of 


AORTIC    INSUFFICIENCY.  1 67 

congestion  produced  by  drawing  a  pencil  lightly  across 
the  skin  of  the  cheek  or  forehead,  and  on  the  nrucous 
membrane  of  the  averted  lower  lip,  by  pressing  a  glass 
microscopic  slide  against  it,  as  suggested  by  F.  C. 
Shattuck. 

Percussion  discloses  increased  dulness  to  the  left  and 
downward,  and  also,  sometimes,  in  advanced  cases, 
upward  to  the  left  of  the  sternum,  not  from  hypertrophy 
of  the  left  auricle,  but  to  enlargement  of  the  ventricle 
upward. 

Auscultation  recognizes  a  diastolic  murmur,  long  and 
various  in  quality,  but  usually  blowing  and  harsher  than 
the  aortic  obstructive  murmur.  Its  area  of  maximum 
intensity  is  commonly  at  the  aortic  interspace  or  mid 
sternum,  sometimes  as  low  as  the  4th  left  costal  cartilage, 
and  even  at  the  apex  and  at  the  ensiform  cartilage. 
Hence  it  may  be  mistaken  for  the  mitral  obstiuctive 
murmur  and  for  the  murmur  of  tricuspid  stenosis,  but 
both  of  these,  be  it  remembered,  are  unaccompanied  by 
hypertrophy  of  the  left  ventricle.  The  murmur  is  nat- 
urally transmitted  downward  toward  the  ensiform  carti- 
lage or  along  the  left  edge  of  the  sternum,  and  toward 
the  apex  in  the  direction  of  the  regurgitating  column, 
but  it  may  also  be  heard  in  the  direction  of  the  great 
vessels  of  the  neck,  though  less  loudly  than  the  aortic 
systolic  murmur. 

Various  sounds  may  be  heard  in  the  arteries  of  mid- 
dle size,  such  as  the  popliteals  and  femorals.  Included 
in  these  is  Traube's  double  sound  described  on  p.  1,43- 


l68  PHYSICAL   DIAGNOSIS. 


AORTIC  STENOSIS  AND   INSUFFICIENCY. 

This  doable  lesion  is  a  comparatively  frequent  one, 
indeed,  commonly  regarded  as  the  nexf  in  frequency 
after  mitral  incompetency,  and  therefore  more  frequent 
than  either  aortic  stenosis  or  aortic  insufficiency  alone. 
It  occasions  a  double  basic  murmur,  systolic  and  dias- 
tolic, well  named  the  steain-tiig  murmur.  It  is  also  a 
grave  condition  giving  rise  to  the  same  dangers  as  aor- 
tic regurgitation,  and  the  same  enormous  hypertrophy 
of  the  left  ventricle. 

AORTIC  STENOSIS   AND   MITRAL  INSUFFI- 
CIENCY. 

This  is  the  second  in  frequency  of  the  combined  mur- 
murs, according  to  F.  J.  Smith's  s'atistics,  and  these 
murmurs  probablv  as  frequently  indicate  the  corre- 
sponding lesions.  ,  The  murmurs  occur  at  the  same 
time,  /.  (?.,  during  systole,  that  of  aortic  stenosis  in  the 
aortic  area  conducted  into  the  neck;  the  mitral  in  the 
mitral  area  conducted  into  the  axilla,  as  shown  in 
Fig.  39- 

TRICUSPID   INSUFFICIENCY. 

Tricuspid  regurgitation  as  a  primary  condition  is  ex- 
tremely rare,  and  when  present  is  probably  the  result  of 
an  endocarditis  during  foetal  life,  endocarditis  at  this 
period  being  more  prone  to  attack  the  right  than  the 
left  side.  Endocarditis  involving  the  tricuspid  valve 
may,  however,  occur  in  children,  according  to  Byrom 


TRICUSPID    REGURGITATION. 


169 


Bramwell,*  more  commonly  than  has  been  supposed. 
Infectious  or  mycotic  endocarditis  also  affects  the  tri- 
cuspid valve,  according  to  William  Osier,  in  19  out  of 
238  cases.  More  frequently  tricuspid  regurgitation  is 
one  of  the  terminal  events  of  mitral  disease,  the  tricus- 


FiG.  39. — Combined  Aortic  and  Mitral  Systolic  Murmurs. — {After  Hutchi- 
S071  and  Rainy.') 


pid  orifice  yielding  to  the  dilatation  of  the  right  ven- 
tricle which  succeeds  upon  its  hypertrophy  if  the  patient 
live  long  enough.  It  is  also  one  of  the  possible  sequelae 
of  emphysema  of  the  lungs  and    long-standing   fibroid 


A??ier.  your.  Med.  Sci.,  Apr.,  1886,  p.  419. 


170  PHYSICAL   DIAGNOSIS. 

phthisis.  Its  effects,  depending  upon  engorgement  of 
the  venous  circulation,  have  aheady  been  detailed  on 
p.  156. 

In  primary  tricuspid  insufificiency  with  regurgita- 
tion, inspection  and  palpation  note  an  apex  beat  dif- 
fused from  the  normal  area  toward  the  epigastrium,  and 
percussion  may  detect  enlargement  toward  the  right  of 
the  end  of  the  sternum. 

To  anscultation  the  systolic  murmur  thus  engendered 
is  invariably  feeble  and  is  heaid  almost  solely  in  the 
tricuspid  area,  just  above  and  to  the  left  of  the  ensiform 
cartilage.  Occasionally  only  is  the  second  pulmonic 
sound  accentuated.  There  should  be  no  confounding 
of  this  murmur  with  that  of  aortic  regurgitation  con 
ducted  toward  the  same  situc^tion,  nor  with  that  of  mitral 
regurgitation  heard  at  no  gieat  distance,  for  the  reasons 
named.  To  these  must  be  added  a  difference  in  quality 
and  pitch  between  the  tricuspid  and  the  mitral  murmur. 
The  jugular  pulse  is  also  more  or  less  constantly  asso- 
ciated with  tricuspid  regurgitation.  The  presence  of  the 
pulsating  liver  is  almost  pathognomonic.  The  jugular 
pulse  is  sysolic  in  time  and  does  not  appear  until  the 
valves  situated  at  the  opening  of  the  internal  jugulars 
into  the  innominate  veins  yield.  These  give  way  first 
on  the  right  side  because  the  communication  is  more 
direct.  The  false  jugular  pulse  must  not  be  mistaken 
for  the  true  one.  It  is  commonly  more  superficial,  and 
is  found  whenever  the  venous  system  is  much  engorged, 
whether  in  health  or  disease.  It  is  presysolic  in  time, 
while    the   jugular    is    systolic,    but    is  easiest    distin- 


TRICUSPID    STENOSIS.  171 

guished  by  pressing  on  the  vein  above  the  valves,  which 
will  cause  the  false  pulse  to  disappear,  while  the  true 
pulse,  coming  from  the  right  ventricle,  will  remain 


TRICUSPID   STENOSIS. 

Tricuspid  stenosis  is  a  still  more  rare  condition  than 
primary,  tricuspid  incompetency,  but  it  may  occur  in 
association  with  left-sided  heart  disease  as  the  result  of 
rheumatic  endocarditis  and  unknown  causes.  As  in 
endocarditis  of  the  left  side,  there  is  thickening, ' 
adhesion,  narrowing.  These  cases  are  regarded  as  most 
frequently  acquired,  not  congenital,  although  the  diag- 
nosis is  seldom  made  because  the  murmur  is  masked  by 
the  mitral  systolic  muimur  which  is  usuall).  associated. 

Tricuspid  obstruction  without  coincident  mitral  dis- 
ease is  exceedingly  rare.  A  presystolic  tricuspid  mur- 
mur pointing  to  such  a  condition  in  a  case  observed  by 
Gardner  was  found  due  to  a  growth  from  the  endocar- 
dium of  the  right  auricle,  so  placed  as  to  fall  over  the 
tricuspid  orifice  in  the  manner  of  a  ball  valve. 

Congenital  defects  would  include  other  cases. 

Shattuck  has  met  one  instance  of  tricuspid  stenosis 
with  mitral  stenosis  and  regurgitation,  along  with 
adherent  pericardium,  hepatic  cirrhosis,  and  slightly 
granular  kidney,  determined  by  autopsy.  In  this  rase 
there  was  a  presystolic  tricuspid  murmur  observed  for 
three  years  before  death. 

To  auscultation^  a  presystolic  murmur  at  the  light 
edge  of  the  sternum  from  the  4th  costal  cartilage  to  the 


172  PHYSICAL    DL4GN0SIS. 

ensiform  cartilage  and  thence  to  the  6th  left  cartilage  at 
its  junction  with  the  sternum,  would  be  the  murmur  diag- 
nostic of  the  condition.  Frequently  there  is  no  mur- 
mur audible,  even  if  such  a  lesion  is  found  at  necropsy. 
There  should  also  be  enlargement  of  the  right  auricle. 
A  presystolic  thrill  may  accompany  the  murmur. 


PULMONARY  STENOSIS 

The  great  majority  of  systolic  murmurs  heard  at  the 
pulmonary  orifice  are  functional.  Pulmonary  stenosis 
may,  however,  be  present,  and  where  .it  exists  it  is  far 
more  likely  to  be  congenital  from  arrested  development, 
although  intra-uterine  endocarditis  may  also  cause  it. 
So,  also,  may  infectious  endocarditis,  and  in  rare  in- 
stances atheroma. 

Pulmonary  stenosis  should  furnish  a  systolic  murmur 
in  the  pulmonary  area,  to  the  left  of  the  sternum.  The 
murmur  may  even  be  heard  behind,  between  the  shoul- 
ders, and  it  may  be  rough.  It  is  accompanied  by 
hypertrophy  of  the  right  ventricle.  There  may  be  a 
basic  thrill,  as  in  aortic  obstruction,  but  the  pulse  is 
uninfluenced.  Compensation  may  be  set  up  by  means 
of  a  patulous  foramen  ovale,  an  open  ductus  arteriosus, 
or  interventricular  communication.  The  invariable  asso- 
ciation of  cyanosis  due  to  venous  obstruction  and  of 
attacks  of  dyspnoea  complete  the  picture  and  aid  greatly 
in  the  diagnosis.  Ansemic  murmurs  at  the  same  time 
and  place  are  unaccompanied  by  cyanosis. 

Walshe  has  described  a  case  of  death  from  thrombosis 


CONGENITAL    DEFECTS.  1 73 

of  the  pulmonary  artery  in  which  he  heard  a  pulmonary 
systolic  murmur  before  the  end  came. 


PULMONARY  INSUFFICIENCY. 

Simple  pulmonary  regurgitation  is  scarcely  known, 
but  it  is  easy  from  what  has  gone  before  to  deduce  the 
physical  signs  which  are  to  be  expected — a  diastolic 
murmur  heard  in  the  pulmonic  area,  hypertrophy  of  the 
right  ventricle,  jugular  pulse,  venous  congestion,  and 
cyanosis.  A  few  cases  are  related  in  which  a  diastolic 
murmur  has  been  found  associated  with  defects  in  the 
pulmonary  valves,  in  one  warty,  which  might  have  been 
•the  result  of  infectious  endocarditis.  All  others  are 
congenital.  Among  them  is  aneurismal  dilatation.  Such 
was  a  case  reported  to  the  Pathological  Society  of  Phila- 
delphia by  Edward  T.  Bruen.  (See  Transactions  for 
1883.) 

It  must  not  be  forgotten  that  occasionally  systolic  and 
diastolic  murmurs  produced  by  aortic  disease  are  best 
heard  in  the  second  left  interspace  instead  of  the  right. 


CONGENITAL   DEFECTS. 

Congenital  defects  in  the  cardiac  valves  and  orifices 
deserve  a  passing  notice.  They  may  be  the  result  of 
endocarditis  during  foetal  life  or  of  arrest  of  develop- 
ment. Their  most  frequent  seat  is  the  right  heart  and 
the  most  frequent  form  is  stenosis  of  the  pulmonary 
orifice,  the  effects  and  signs  of  which  have  already  been 


174  PHYSICAL    DIAGNOSIS. 

considered.  Another  is  a  permanently  patulous  foramen 
ovale;  or  there  may  be  a  defect  of  the  septum  of  the 
ventricles,  or  a  communication  between  the  aorta  and 
pulmonary  artery — a  persistent  ductus  arteriosus — or 
between  the  aorta  and  the  vena  cava  or  right  auricle. 
All  of  these  intercommunications  produce  murmurs  dif 
ficult  to  separate,  and  it  is,  after  all,  by  attention  to  the 
general  condition  that  the  defect  is  recognized.  The 
patient,  a  child  of  arrested  development,  more  or  less 
permanently  cyanosed,  with  continued  embarrassed 
breathing,  all  of  these  are  conditions  which  point  to  the 
congenital  defect.  If  there  be  added  to  these  a  persist- 
ent loud  murmur  at  the  base  of  the  heart  without  other 
signs  or  symptoms  of  valvular  disease,  this  may  be  due 
to  congenital  defect. 


RELATIVE  FREQUENCY  AND  RELATIVE  DAN- 
GER OF  VALVULAR  DEFECTS. 

The  order  of  frequency  of  the  various  valvular  defects 
is  not  entirely  agreed  upon.  As  to  one,  however,  there 
seems  to  be  universal  concurrence,  and  that  is  that 
mitral  regurgitation  is  the  most  frequent.  After  this, 
however,  statistics  diiTer.  Thus  of  the  older  authors 
Walshe  presents  the  following  order  of  frequency  for 
the  single  or  individual  murmurs  : 

I.  Mitral  incompetency  or  insufficiency.  2.  Aortic 
stenosis.  3.  Aortic  incompetency.  4.  Mitral  stenosis. 
5.  Tricuspid  incompetency.  6.  Pulmonary  stenosis. 
7.  Tricuspid     stenosis.      8.  Pulmonary    incompetency. 


VALVULAR    DEFECTS.  175 

As  already  stated,  all  agree  that  the  mitral  systolic 
murmur  indicating  mitral  regurgitation  is  the  most  fre- 
quent. Dr.  Frederick  J.  Smith,  analyzing  the  registers 
and  post-mortem  records  of  the  London  hospitals  for 
eleven  years — 1877-1887 — and  taking  the  fatal  cases 
only,  arrived  at  the  following  order  : 

I.  Mitral  incompetency.  2.  Mitral  stenosis.  3. 
Aortic  incompetency.  4.  Aortic  stenosis.  5.  Tricuspid 
stenosis. 

Out  of  the  705  cases  Smith  found  26,  or  3.38  per 
cent.,  of  mitral  stenosis,  and  25,  or  3.25  per  cent.,  of 
aortic  regurgitation.  So  it  cannot  be  said  there  is  any 
practical  difference  in  the  relative  frequency  of  these 
two  lesions.  Smith's  statistics,  being  recent  and  based, 
as  they  are,  upon  the  examination  of  registers  and  au- 
topsy records,  might  be  reasonably  regarded  as  correct. 
Yet  it  is  not  easy  to  disprove  the  presence  of  a  coinci- 
dent regurgitation  in  many  cases  of  anatomical  stenosis, 
which  would,  therefore,  have  to  be  deducted  from  the 
cases  of  simple  lesion  and  added  to  those  of  com- 
bined. 

G.  Klemperer  considers  simple  mitral  stenosis — /.  e., 
occurring  alone — very  rare,  and  says  the  same  of  aortic 
stenosis,  aortic  incompetency  being  very  frequent  and 
mitral  incompetency  the  most  frequent  of  all  cardiac 
defects,  and  I  am  inclined  with  him  to  make  the  fol- 
lowing order : 

I.  Mitral  incompetency.  2.  Aortic  incompetency. 
3.  Aortic  stenosis.  4.  Mitral  stenosis.  5.  Tricuspid 
incompetency. 


176  PHYSICAL   DIAGNOSIS. 

Two  murmurs  at  one  orifice  are  usually  characterized 
as  "  double  "  murmurs,  but  Sansom  suggests  that  the 
term  "  combined  "  be  applied  to  these  murmurs,  and 
the  term  "  associated  "  retained  for  murmurs  at  more 
than  one  orifice. 

F.  J.  Smith's  results  as  to  associated  murmurs  are  as 
follows  ; 

1.  Aortic  regurgitation  and  stenosis  3  mitral  regurgi- 
tation. 

2.  Aortic  stenosis  and  mitral  regurgitation. 

3.  Aortic  regurgitation  and  mitral  regurgitation. 

4.  Aortic  regurgitation  and  stenosis ;  mitral  stenosis 
and  regurgitation. 

5.  Mitral  regurgitation  and  tricuspid  regurgitation. 

6  Aortic  regurgitation  and  stenosis ;  mitral  regurgi- 
tation; tricuspid  regurgitation. 

7.  Mitral  stenosis  and  regurgitation;  tricuspid  re- 
gurgitation. 

8.  Aortic  stenosis ;  mitral  stenosis  and  regurgitation. 

9.  Aortic  regurgitation  ;  mitral  stenosis  and  regurgi- 
tation. 

10.  Aortic  stenosis;  mitral  regurgitation;  tricuspid 
regurgitation. 

11.  Aortic  regurgitation  and  stenosis;  mitral  regur- 
gitation; pulmonary  regurgitation. 

12.  Aortic  stenosis  and  regurgitation  ;  mitral  stenosis. 

13.  Aortic  regurgitation ;  mitral  stenosis. 

14.  Aortic  regurgitation  ;  mitral  regurgitation  ;  tri- 
cuspid regurgitation. 

15.  Mitral  stenosis  ;  tricuspid  regurgitation. 


VALVULAR    DEFECTS.  I  77 

i6.  Aortic  stenosis;  mitral  stenosis  and  regurgita- 
tion ;  tricuspid  regurgitation. 

17.  Aortic  stenosis ;  mitral  stenosis. 

18.  Aortic  regurgitation  and  stenosis;  mitral  stenosis 
and  tricuspid  regurgitation. 

19.  Aortic  regurgitation  ;  mitral  stenosis  and  regurgi- 
tation ;   tricuspid  regurgitation. 

20.  Aortic  regurgitation  and  stenosis ;  mitral  stenosis 
and  regurgitation  ;  tricuspid  regurgitation. 

21.  Aortic  regurgitation  and  stenosis;  mitral  stenosis 
and  regurgitation  ;  tricuspid  stenosis  and  regurgitation. 

22.  Aortic  stenosis ;  pulmonary  stenosis. 

23.  Aortic  stenosis ;  mitral  stenosis  and  regurgita- 
tion ;  tricuspid  stenosis  and  regurgitation. 

24.  Mitral  stenosis  and  tricuspid  stenosis. 

Of  the  loth  and  nth  there  are  the  same  number,  5 
out  of  705  ;  of  the  12th,  13th,  and  14th,  each  4,  and  of 
the  last  5  each  i.  Of  the  double  or  combined  murmurs, 
it  is  generally  conceded  that  that  at  the  mitral  orifice, 
indicating  stenosis  and  insufficiency,  is  the  most  fre- 
quent, and  women  are  far  more  liable  to  this  lesion  than 
men.  In  an  analysis  of  cases  at  the  Glasgow  Infirmary, 
Dr.  George  S.  Middleton  found  a  far  larger  proportion 
of  the  double  aortic  lesion  than  Dr.  Smith,  22  per 
cent,  as  against  4  per  cent.,  and  Walshe  makes  the 
double  aortic  lesion  the  second  in  frequency.  But 
when  we  add  together  the  cases  of  double  aortic  lesion 
and  those  of  double  aortic  lesion  combined  with  lesions 
at  the  other  valves,  as  suggested  by  Dr.  Sansom,  we 
have    almost    exactly    22     per    cent.,    and    it    is    well 


178  PHYSICAL    DIAGNOSIS. 

known  that  in  the  majority  of  cases  affecting  the  aortic 
valves,  the  mitral  and  tricuspid  valves  become  sooner  or 
later  affected. 

Although  but  one  case  of  tricuspid  stenosis  associated 
with  mitral  stenosis  is  found  by  Smith  in  his  705  cases, 
Bedford  Fenwick  has  collected  a  large  number  of  cases 
of  stenosis  of  the  tricuspid  orifice,  in  which  the  lesion 
was  almost  invariably  accompanied  by  stenosis  of  the 
mitral  orifice.  Dr.  Wilks  regards  the  narrowing  of  the 
mitral  orifice'  in  these  cases  as  secondary  to  that  of  the 
tricuspid,  which  allows  only  a  small  quantity  of  blood  to 
pass  into  the  right  ventricle  and  lungs,  in  consequence 
of  which  a  like  small  amount  passes  to  the  left  heart, 
whence  a  reduction  in  the  size  of  its  cavities  and  orifices. 

The  relative  danger  of  cardiac  affections,  beginning 
with  the  most  serious,  is  also  given  by  Walshe  as  fol- 
lows : 

1.  Tricuspid  incompetency. 

2.  Mitral  stenosis  and  incompetency. 

3.  Aortic  incompetency. 

4.  Pulmonary  stenosis. 

5.  Aortic  stenosis. 

It  will  be  remembered,  however,  that  I  have  said  that 
aortic  regurgitation  is  the  most  irremediable  of  the 
valvular  defects,  at  least  of  the  more  common  forms,  and 
the  most  serious  from  the  standpoint  of  tendency  to 
sudden  death.  It  will  be  noted  that  no  place  is  assigned 
by  Walshe  to  simple  mitral  obstruction,  and  it  is  indeed 
difficult  to  assign  the  final  position  of  this  lesion  with  a 


ACUTE    ENDOCARDITIS.  I  79 

good  left  auricle.  Such  cases  run  along  for  a  long  time, 
but  the  resulting  congestion  of  the  lung  is  troublesome, 
and  invites  to  circumscribed  pneumonias,  which  are  of 
frequent  occurrence. 

ACUTE   ENDOCARDITIS. 

The  two  well-acknowledged  forms  of  endocarditis, 
simple  and  infectious  or  ulcerative,  furnish  no  dis- 
tinctive physical  signs  by  which  they  can  be  recognized 
one  from  the  other.  It  is  rather  by  the  history  and 
symptoms  that  such  distinction  is  made,  the  almost 
invariable  succession  of  the  former  upon  rheumatism 
and  of  the  latter  on  some  coexisting  infectious  state 
being  valuable  aids.  The  evident  septic  character  of 
the  latter  as  indicated  by  chills,  fever,  and  sweats  is 
also  distinctive. 

Both  have  their  most  frequent  site  on  the  left  side, 
the  most  vulnerable,  and  in  Ihe  mitral  leaflets.  A  sys- 
tolic mitral  murmur,  in  the  course  of  a  rheumatism, 
means  almost  invariably  an  endocarditis.  The  aortic 
leaflets  may  also  be  the  seat  of  inflammation,  though  less 
frequently,  when  a  basic  murmur  is  the  consequence.  But 
not  every  aortic  murmur  in  the  course  of  rheumatism 
implies  endocarditis,  as  the  condition  of  the  blood  pre- 
disposes to  a  hsemic  murmur;  nor  every  murmur  at  the 
apex,  because  the  state  of  the  muscle  predisposes  to 
imperfect  closure  of  the  auriculo-ventricular  orifice. 
Unless  there  has  been  previous  valvular  disease,  there  is 
no  enlargement,  so  that  neither  palpation,  inspection, 
nor  percussion  gives  any  information. 


l80  PHYSICAL   DIAGNOSIS. 


PERICARDITIS. 


The  only  distinctive  physical  sign  in  the  first  stage 
of  pericarditis  is  the  friction  sound,  described  on  p.  137. 
In  addition,  the  impulse  may  be  strong. 

The  SECOND  stage,  or  that  of  effusion,  has  usually,  but 
not  always,  signs  discoverable  to  inspection  and  palpa- 
tion. The  prsecordium  may  be  bulging  and  the  inter- 
spaces obliterated,  and  the  impulse  undulating,  tumul- 
tuous, feeble,  and  indistinct.  The  prcecordium  may 
be  tender  to  pressure.  Percussion  furnishes  the  most 
striking  change.  The  area  of  dulness  is  enlarged, 
and  peculiarly  enlarged;  It  becomes  rudely  triangular, 
with  the  apex  toward  the  inner  end  of  the  left  clavicle, 
and  the  base  as  low  as  the  7th  rib,  and  extending  in 
extreme  cases  from  nipple  to  nipple.  Yet  I  have  seen 
enlargement  identical  in  shape  and  extent  with  this, 
produced  by  enormous  hypertrophy  associated  with 
pericardial  friction. 

The  dorsal  test  for  pericardial  effusion,  to  which 
attention  was  called  by  William  Ewart,*  consists  in  the 
recognition  by  percussion  of  a  rectangular  area  of 
dulness  from  the  9th  or  loth  to  the  12th  rib  on  the  left 
side  of  the  median  line  behind.  It  is  ascribed  mainly 
to  a  displacement  of  the  liver,  due  to  depression  of  the 
anterior  surface  of  the  liver  downward  under  the  weight 
of   the  pericardial  effusion,  tilting   the   mass  of  the  left 

*  Brit.  Med.  Jour.,  March  21,  1896,  and  Jan.  23,  1897. 


DISEASES    OF   THE    MYOCARDIUM.  T6I 

lobe  backward.  The  test  is  of  no  value  in  children,  in 
whom  the  dull  patch  is  normally  present,  as  here  the 
liver  is  large  and  the  thorax  is  short.  The  same  normal 
dulness  is  present  in  wasted  adults  and  also  invalidates 
the  test  in  them.  Instances  are  met  in  cases  of  phthisis 
with  enlarged  liver.  The  same  condition  is  possible  in  the 
emaciated  person  of  the  convalescent  from  typhoid  fever. 

Auscultation  confirms  palpation  ;  the  impulse  is  feeble, 
indistinct,  and  often  tumultuous.  The  heart-sounds  are 
indistinct  and  best  heard  at  the  top  of    the  sternum. 

The  THIRD  STAGE  consists  in  a  gradual  return  to  the 
normal  state  of  affairs,  which  may  be  by  the  intermedi- 
ation of  a  friction  redux  or  not.  Adhesions  may  result 
between  the  heart  and  the  sac,  embarrassing  its  move- 
ments permanently,  and  producing  retraction  of  the 
chest-wall  with  systole.  On  the  other  hand,  necropsy  has 
often  revealed  close  adhesions  between  the  heart  and 
the  pericardium  which  were  not  suspected  during  life. 
Permanent  roughening  by  organization  in  chronic  peri- 
carditis may  produce  permanent  friction  sound. 

Hydropericardium,  as  a  part  of  a  general  dropsy, 
is  a  rare  condition,  and  furnishes  the  same  physical  signs 
as  the  inflammatory  effusion. 


DISEASES   OF  THE    MYOCARDIUM. 

The  heart  is  subject  to  alterations  in  its  muscular  sub- 
stance independent  of  valvular  defect.  Simple  hyper- 
trophy, dilatation,  fatty  infiltration,  and  fatty  metamor- 
phosis, or  true  fatty  degeneration,  are  the  most  important. 


I  82  Pm^SICAL    DL4.GNOSIS. 

I\Iyositis,  abscesses,  and  aneurisms  of  the  walls  of  the 
heart  are  such  rare  conditions  that  they  need  only  to  be 
mentioned  in  passing,  especially  as  there  is  no  way  to 
recognize  them  before  death. 

Hypertrophy  of  the  left  ventricle,  without  val- 
vular disease,  is  always  the  result  of  obstruction  to  the 
movement  of  the  blood  through  the  aorta  beyond  the 
valves,  or  to  some  demand  for  compensation.  The  most 
common  remote  cause  is  chronic  Bright's  disease.  Any 
variety  of  chronic  Bright's  disease  may  cause  it,  but  it 
is  most  frequently  associated  with  chronic  interstitial 
nephritis.  We  have  nothing  to  do  here  with  the  mech- 
anism of  its  production,  except  to  say  that  it  has  always 
seemed  to  me  to  be  in  some  degree  coirpensatory. 
Arterial  scleiosis  (atheroma)  and  aneurism  of  the  aorta 
are  attended  by  less  degrees  of  hypertrophy,  also  com- 
pensatory, because  of  the  loss  of  the  elastic  force  in  the 
arteries,  requiring'  additional  power  on  the  part  of  the 
heart  muscle.  Excessive,  long-continued  muscular  exer- 
tion and  excessive  liquid  ingestion  may  produce  it — the 
beer  heart. 

Inspection  and  palpation  furnish  much  the  same  in- 
formation as  in  hypertrophy  of  the  left  ventricle  from 
valvular  disease.  Percussion  shows  enlargement  to  the 
left  and  downward.  To  auscultation  there  is  no  murmur, 
but  a  distinctive  intensification  of  the  aortic  second  sound 
is  heard,  quite  characteristic,  and  itself  of  great  diagnostic 
value.  The  first  sound,  while  louder,  is  also  duller,  more 
prolonged,  and  diffuse,  qualities  which  sometimes  suggest 
a  systolic  mitral  murmur  which  is  not  present. 


DISEASES    OF    THE    MYOCARDIUM.  1 83 

Pure  hypertrophy  of  the  right  ventricle  occurs 
as  the  result  of  emphysema  of  the  lungs,  and  sometimes, 
to  a  less  degree,  of  fibroid  disease  of  the  same  organs, 
compression  of  the  lungs  by  pleural  effusion  or  adhesion, 
or  of  any  cause  which  resists  the  movement  of  the  blood 
from  the  right  heart.  We  have  here  the  signs  of  enlarge- 
ment in  the  direction  of  the  right  heart,  also  without 
murmur,  but  with  sharp  accentuation  of  the  second 
sound  at  the  pulmonary  interspace  to  the  left  of  the 
sternum. 

General  hypertrophy  or  physiological  hypertro- 
phy or  symmetrical  hypertrophy  of  both  sides  of  the 
heart  may  be  brought  about  by  severe  muscular  exercise, 
demanding  extra  nourishment.  Exophthalmic  goitre  is 
often  accompanied  by  the  same  condition,  due  to  over- 
nourishment,  the  result  of  vaso-dilator  influence  on  the 
blood-vessels. 

Dilatation  of  the  heart,  either  of  its  right  or  left 
ventricle,  may  occur  independently  of  valvular  disease. 
A  heart  cavity  is  said  to  be  dilated  when  it  is  enlarged 
out  of  all  proportion  to  the  thickness  of  its  walls,  even 
though  the  latter  may  be  somewhat  thicker  than  normal. 
Commonly,  however,  the  walls  are  thinner  or  no  thicker 
than  in  health,  and  when  the  muscular  wall  is  thick- 
ened while  the  cavity  is  enlarged  we  commonly  speak 
of  the  condition  as  hypertrophy  with  dilatation. 
The  term  simple  dilatation  is  used  to  indicate  undue 
enlargement  of  the  cavity  while  the  walls  remain  of 
normal  thickness;  attenuated  dilatation  where  the 
walls  are  thinned.    Dilatation  in  chronic  cardiac  disease 


184  Pm^SICAL   DL4GN0SIS. 

is  commonly  associated  with  fatty  degeneration,  but  it 
is  hardly  likely  that  there  is  fatty  degeneration  in  acute 
dilatation,  else  recovery  which  occurs  would  hardly  be 
possible. 

Dilatation  "without  valvular  disease  occurs 
rapidly  and  slowly  :  Rapidly  in  connection  with  grave 
cases  of  the  acute  infectious  diseases  attended  with 
degeneration  of  the  muscular  substance  of  the  heart. 
Such  are  typhus  fever,  typhoid  fever,  scarlet  fever, 
smallpox,  acute  rheumatism, .  and  infectious  endo- 
carditis. More  slowly  in  connection  with  vesicular 
emphysema,  when,  of  course,  it  is  in  the  right  heart, 
and  succeeds  hypertrophy.  Tobacco  and  alcohol  are 
conspicuous  cases  of  such  dilatation  ;  also  insufficient 
food,  inanition,  anaemia,  and  old  age.  In  like  manner 
the  h3'pertrophied  left  ventricle  of  chronic  Bright's 
disease  may  become  dilated.  Whatever  causes  obstruc- 
tion to  the  outward  flow  of  blood  from  a  ventricle  may 
cause  dilatation,  which  is  always,  however,  preceded  by 
hypertrophy.     Aneurism  is  such  a  cause  for  the  left  heart. 

hispection  and  palpation  discover  a  diffuse  feeble 
impulse  and  the  pulse  is  weak.  Percussion  elicits  signs 
of  enlargement,  while  auscultation  finds  the  sounds  gen- 
erally feeble  and  indistinct.  I  speak  now  of  dilatation 
without  valvular  disease.  When  vahoilar  disease  is 
present  its  signs  are  superadded. 

Fatty  infiltration  or  obese  heart  is  often  a  part  of 
the  conditions  of  general  obesity  and  has  the  same 
causes.  It  is  something  ver}'  different  from  the  true 
fatty  heart,  or  fatty  metamorphosis,  in  which  the  mus- 


DISEASES    OF   THE    MYOCARDIUM.  1 85 

cular  fasciculi  are  converted  into  granular  fat.  In  the 
fatty  infiltration  the  fat  first  covers  the  surface  of  the 
heart,  then  insinuates  itself  between  the  fasciculi,  and 
although  these  are  never  themselves  invaded,  in  extreme 
cases  they  undergo  degeneration  and  atrophy  from  the 
pressure  of  the  intervening  fat.  The  heart  is  therefore 
not  only  embarrassed  by  the  fat  around  and  between  its 
fibres,  but  the  integrity  of  its  essential  substance  may 
also  be  impaired  by  interference  with  its  nutrition,  and 
occasionally  death  results  from  sudden  failure,  just  as  in 
true  fatty  metamorphosis. 

Such  a  heart  is  usually  somewhat  symmetrically  en- 
larged, but  the  heart-sounds  are  feeble  and  indistinct, 
and  the  same  is  true  of  the  impulse.  There  are,  of 
course,  no  murmurs  unless  the  condition  be  complicated 
with  valvular  disease. 

Its  recognition  is  based  chiefly  on  the  association  of 
the  symptoms  of  cardiac  weakness  with  general  obesity. 

True  fatty  metamorphosis  consists  in  an  actual 
substitution,  to  a  greater  or  less  extent,  of  the  muscular 
substance  of  the  heart  by  granular  fat.  It  is  constantly 
associated  with  dilatation  of  the  heart.  Such  a  heart 
muscle  is  soft  and  flabby,  and  its  contraction  power  is 
greatly  impaired. 

Th^  physical  signs  oi  such  a  condition  are  not  at  all 
distinctive.  There  is  feebleness  of  sounds  and  impulse. 
The  latter  as  well  as  the  pulse  may  even  be  inappre- 
ciable. There  may  be  some  enlargement  of  the  heart, 
the  result  of  dilatation  of  the  soft  and  yielding  muscle. 
Nor  is  there  murmur  unless  there  be  valvular  disease. 


I  86  PHYSICAL    DUGNOSIS. 

It  is  rather  by  watching  a  case  over  a  considerable 
period  of  time  that  the  truth  is  arrived  at.  Treatment 
is  without  result,  and  its  total  inefficiency  is  an  aid  in 
diagnosis.  Fainting  is  frequent  and  sudden  death  the 
usual  termination. 

Acute  myocarditis  associated  with  acute  rheuma- 
tism or  fever  may  be  a  cause  of  fatty  degeneration,  but 
there  is  no  way  of  determining  with  certainty  its  pres- 
ence. It  may  be  suspected  when,  along  with,  or  subse- 
quent to,  intense  rheumatic  fever,  there  is  evidence  of 
heart  failure. 

Myocarditis—  Fibroid  Heart.  Slight  degrees 
occasion  no  sjmptoms,  while  autopsies  even  disclose 
advanced  stages  of  indurative  myocarditis  which  were 
not  suspected.  In  consequence  of  the  frequent  associa- 
tion of  endocarditis  and  pericarditis  with  myocarditis, 
the  symptoms  of  these  diseases  often  mask  the  distinctive 
symptoms  of  the  fibroid  cuange.  Unmasked,  the  symp- 
toms are,  in  a  word,  those  of  dilatation  of  the  heart, 
including  dyspncea,  palpitation,  small,  frequent,  and 
irregular  pulse,  prsecordial  oppression  or  attacks  of  faint- 
ness,  and,  finally,  venous  stasis  with  cyanosis,  oedema, 
and  congestion  of  the  liver,  stomach,  and  kidneys, 
feeble  digestion,  and  scanty  urine.  These  symptoms 
may  set  in  gradually  or  suddenly.  On  such  a  heart 
digitalis  and  other  heart  tonics  are  without  effect.  A 
persistently  slow  pulse  is  an  occasional  symptom.  An- 
gina pectoris  may  also  be  a  symptom  of  indurative 
myocarditis,  though  it  also  occurs  in  other  cardiac  dis- 
eases, especially  aortic  stenosis. 


DISEASES    OF    THE    MYOCARDIUM.  1 87 

Physical  Signs. — Physical  examination  recognizes  a 
feeble  impulse  and  on  percussion  enlargement  of  the 
heart — dilatation.  The  first  sound  lacks  its  muscular 
element  and  is  nrore  like  the  second,  more  purely 
valvular,  and  therefore  short.  Both  maintain  for  a 
time  considerable  distinctness  but  ultimately  grow 
feeble.  Occasionally  there  is  a  mitral  murmur,  which 
may  be  functional  and  transitory,  or  permanent.  This 
is  explained  by  the  experinrents  of  Ludwig  and  Hesse, 
confirmed  by  Krehl,  which  go  to  show  that  a  certain 
integrity  of  the  muscles  about  the  mitral  orifice  or  of 
the  papillary  muscles  is  necessary  to  a  complete  closure 
of  the  latter.  Such  integrity  is  impaired  by  myocarditis, 
and  the  resulting  murmurs  increase  the  difficulties  of 
diagnosis.  There  is,  however,  usually  absence  of  ac- 
centuation of  the  pulmonic  second  sound  characteristic 
of  mitral  regurgitation,  though  this  may  also  be  relatively 
present  if  the  right  ventricle  happens  to  be  less  severely 
involved.  The  second  sound  is  also  sometimes  redupli- 
cated. The  mitral  murmur  in  the  fibroid  heart  is  more 
variable,  more  subject  to  intermissions,  than  that  of 
mitral  regurgitation.  The  sudden  addition  of  a  mitral 
systolic  murmur  in  a  fibroid  heart  previously  without  a 
murmur  may  be  due  to  a  lacerated  valve. 

Prolonged  study  of  the  case  is  often  necessary  before 
a  diagnosis  is  possible.  For  the  most  part  we  are  com- 
pelled to  rely  on  the  absence  of  the  symptoms  and  signs 
of  valvular  disease  and  the  presence  of  the  symptoms  of 
dilatation,  the  evidences  of  arterio-sclerosis  elsewhere,  a 
persistently   slow  pulse,  angina  pectoris,  the   history  of 


1 88  PHYSICAL   DIAGNOSIS. 

syphilis  and  of  other  causes,  together  with  the  age  of 
the  patient.  Where  the  fibroid  condition  is  associated 
with  murmurs,  the  diagnosis  is  still  more  difficult,  and 
must,  indeed,  be  a  matter  of  probability  if  even  sug- 
gested, so  much  more  likely  are  the  signs  to  be  inter- 
preted as  those  of  valvular  disease  alone. 


THORACIC  ANEURISM. 

Thoracic  aneurism  occurs  in  the  ascending,  transverse, 
and  descending  portions  of  the  arch  of  the  aorta,  and  in 
the  thoracic  aorta  below  the  arch.  The  greater  fre- 
quency of  aneurism  in  the  male  sex  and  during  early 
middle  life  may  be  mentioned. 

The  pressure  symptoms  of  thoracic  aneurism  are 
so  important,  so  frequently  precede  the  physical  signs, 
and  so  frequenth'  are  necessary  to  a  correct  diagnosis, 
that  their  consideration  is  indispensable  and  wiil  be 
added  after  a  study  of  the  physical  signs. 

Physical  Signs  of  Aneurism  of  the  Arch. 

Inspection  does  not  always  discover  changes,  but  if 
the  sac  grows  outwardly,  sooner  or  later  a  promi- 
nence thus  makes  its  appearance ;  to  the  right  of  the 
sternum  the  sac  is  in  the  ascending  limb,  possibly  rais- 
ing a  rib  or  the  end  of  the  clavicle ;  above  and  behind 
the  sternum,  if  in  the  transverse  portion,  raising  the 
manubrium  or  boring  its  way  through  it;  and  to  the 
left  of  the  sternum  if    in  the  descending  limb  of  the 


THORACIC   ANEURISM.  1 89 

arch.  Such  a  tumor  may  pulsate  visibly  or  not. 
The  aeurism  is,  as  it  were,  a  rudimental  heart, 
dilating  with  every  jet  of  blood  that  is  shot  into  it 
so  long  as  the  wall  is  yielding,  and  contracting  on 
the  withdrawal  of  the  intravascular  pressure.  Should 
these  qualities  be  lost,  either  as  the  result  of  calcifica- 
tion or  the  deposit  within  the  sac  of  successive  layers 
of  coagulum.,  such  dilatation  becomes  impossible,  and 
pulsation  docs  not  occur.  The  pulsation  is,  however, 
of  great  importance  in  diagnosis.  When  present  it  is 
synchronous  with  the  systole  of  the  ventricles.  The 
heart  itself  is  sometimes  displaced  dow?iward,  as  may  be 
recognized  by  the  lowering  of  the  apex. 

If  the  aeurismal  tumor  press  upon  the  great  veins 
of  the  neck  there  may  be  venous  engorgement  on 
one  side  of  the  neck  or  both,  according  as  the  innomi- 
nate vein  of  one  side  only  is  compressed  or  the  descend- 
ing cava  itself. 

Palpation  also  appreciates  the  impulse  of  the 
aneurism,  sometimes  even  when  it  is  not  visible. 
This  beating  is  somewhat  peculiar,  being  expansile, 
and  by  this  pecuharity  differs  from  the  rising  of  a 
tumor  over  a  pulsating  blood-vessel.  A  thrill  is  also 
often  felt,  a  vibration  in  the  walls  of  the  sac  caused  by 
the  whirl  of  the  blood  into  it.  It  is  by  no  means,  how- 
ever, invariable,  and  it  may  come  and  go. 

Percussion  over  the  swelling  of  an  aneurism  invari- 
ably elicits  dulness,  varying  greatly  in  extent.  On  the 
other  hand,  the  adjacent  lung  may  be  compressed  by  an 
aneurismal  tumor,  and  the  area  of  dulness  thus  extended 


190  PHYSICAL    DIAGNOSIS. 

beyond  the  tumor  itself.  In  the  absence  of  swelHng 
there  may  be  no  impairment  of  resonance. 

Auscultation  is  no  exception,  as  compared  with  the 
other  modes  of  physical  investigation,  in  the  incon- 
stancy of  its  results,  sometimes  furnishing  the  most  dis- 
tinctive signs,  while  at  others  it  is  totally  negative. 
The  murmur  or  bruit  heard  over  an  aneurism  is  vari- 
ous. Sometimes  it  is  double,  like  the  sounds  of  the 
heart,  the  first  intense  and  prolonged,  the  second  fainter 
and  shorter.  Sometimes  but  one  murmur  is  produced, 
pystolic,  corresponding  with  the  first  sound  over  the 
ventricles,  but  more  intense;  more  rarely  it  is  diastolic 
only.  More  frequent  than  either  systolic  or  diastolic 
is  the  combined  or  double  murmur,  both  systolic  and 
diastolic.  It  varies  greatly,  being  sometimes  rough, 
sometimes  soft,  sometimes  musical.  The  murmur  is, 
however,  often  absent.  The  mechanism  of  these  sounds 
is  not  settled.  The  systohc  is  most  easily  explained. 
There  can  be  little  doubt  that  it  is  produced  by  the  en- 
trance of  blood  into  the  sac.  When  the  aneurism  is  at 
the  beginning  of  the  aorta,  the  diastolic  murmur  will 
probably  be  an  aortic  regurgitant  murmur,  due  to 
stretching  apart  of  the  aortic  valves.  When  the  aneu- 
rism is  distant  from  the  aortic  orifice,  the  diastolic  mur- 
mur may  be  due  to  the  elastic  recoil  of  the  aneurismal 
sac  propelling  the  blood  through  the  sac  with  additional 
force.  Rarely  there  is  a  diastolic  murmur  only,  prob- 
ably thus  caused. 

But  any  one  or  all  of  these  signs  may  be  wanting. 
Particularly  is  this  the  case  where  the  aneurism  occurs 


THORACIC    ANEURISM.  I9I 

just  after  the  aorta  has  left  the  heart.  The  most  valu- 
able are  the  pulsation,  distinct  and  separate  from  that  of 
the  heart,  and  the  sounds,  separate  and  distinct  from 
those  of  the  heart,  or,  as  graphically  put  by  Da  Costa, 
"  two  hearts,  apparently,  each  with  its  own  distinct 
beat,  its  own  distinct  sounds."  * 

Pressure  Symptoms. — Not  only  may  all  these 
signs  be  wanting,  but  identical  murmurs  may  be  pro- 
duced by  double  aortic  disease,  /.  e.,  aortic  stenosis  with 
regurgitation,  and  I  have  known  a  case  to  be  diagnosed 
as  double  aortic  disease  after  weeks  of  study,  when  the 
autopsy  disclosed  an  aneurism  of  the  ascending  limb  of 
the  arch  of  the  aorta.  It  is  most  important,  therefore, 
to  place  alongside  of  these  the  so-called  pressure  signs 
of  aneurism,  some  of  which  often  precede  the  physical 
signs. 

The  first  of  these  is  pain,  which  may  be  sharp  and 
acute  when  nerves  are  directly  involved,  or  dull  and 
boring  when  the  result  of  pressure  on  the  bone.  In  the 
latter  case,  too,  it  is  localized ;  in  the  former  it  may 
extend  all  over  the  chest  and  down  the  arms,  simulating 
that  of  angina  pectoris.  It  may  be  unilateral.  It  may 
occur  in  aneurism  of  the  ascending  or  descending  part 
of  the  arch. 

Dysphagia  from  pressure  of  the  tumor  on  the  oesopha- 
gus is  also  an  occasional  symptom. 

Other  signs  are  alterations  in  the  voice,  such  as  hoarse- 
ness, aphonia,  stridor;  also  brassy  cough,  and  defective 

*Op.  cit.,  p.  451- 


192  PHYSICAL    DIAGNOSIS. 

vocalization.  Some  of  these  symptoms  may  be  pro- 
duced by  direct  pressure  on  the  trachea  itself,  others  by 
pressure  upon  the  left  recurrent  laryngeal  nerve.  A 
stridulous  voice  unaccompanied  by  dysphagia  or  apho- 
nia was  early  pointed  out  by  Tufnell,  as  indicating  that 
the  pressure  is  on  the  right  side  of  the  trachea  and  does 
not  affect  the  oesophagus  or  recurrent  laryngeal  nerve. 
On  the  other  hand,  hoarseness,  aphonia,  and  defective 
vocalization,  and  various  degrees  of  paralysis  of  the 
vocal  cord  are  due  to  involvement  of  the  left  recurrent 
laryngeal  nerve,  which  passes  round  the  arch  of  the 
aorta.  The  paralytic  phenomena  may  be  present  with- 
out any  other  laryngeal  symptoms.  Hence  any  altera- 
tion of  voice  or  defective  vocalization  in  a  person  pre- 
senting symptoms  of  heart  disease  demands  a  laryngo- 
scopic  examination.  Such  examination  may  show  little 
alteration  in  the  position  of  the  vocal  cords  in  ordinary 
breathing,  or  the  left,  may  be  a  little  nearer  the  median 
line.  In  total  paralysis,  which  is  one  of  abduction  and 
adduction  of  the  left  vocal  cord,  this  cord  stands  in  the 
so-called  cadaveric  position,  /.  <?.,  midway  between  the 
position  of  ordinary  respiration  and  phonation.  On 
deep  inspiration,  however,  the  right  vocal  cord  is  well 
abducted,  the  left  remaining  quiescent.  The  attempt 
at  phonation  is  more  or  less  abortive.  During  it  the 
right  vocal  cord  may  go  to  the  median  line,  leaving  a 
small  opening  between  it  and  the  motionless  left  cord, 
or  it  may  even  cross  the  line  to  its  paralyzed  neighbor. 
If  only  the  abductor  twigs  of  the  left  recurrent  laryn- 
geal nerve    are  involved  in  the  pressure,  there  ensues 


THORACIC   ANEURISM.  1 93 

gradually  a  permanent  shortening  or  "  paralytic  contrac- 
tion "  of  the  antagonistic  adductors,  and  the  paralyzed 
cord  is  drawn  by  this  into  a  position  of  constant  phona- 
tion, — that  is,  into  the  median  line.  The  result  is  that 
the  voice  is  natural,  the  paralyzed  cord  being  in  the 
position  of  adduction,  while  its  tension  is  mainly  regu- 
lated by  the  crico-thyioid  which  is  innervated  from  the 
external  branch  of  the  superior  laryngeal  nerve,  unin- 
fluenced in  aortic  aneurism.  More  rarely  the  right 
nerve  is  involved,  when  the  same  phenomena  may  occur 
in  the  right  vocal  cord. 

These  events  imply,  of  course,  a  functional  destruc- 
tion of  the  nerve,  which  may  either  be  the  result  of 
simple  pressure,  which  will  lead  sooner  or  later  to  struc- 
tural degenerative  change,  or  the  latter  may  be  due  to 
a  primary  neuritis.  The  early  stages  of  this,  together 
with  an  associated  irritation  of  the  entire  pneumogas- 
tric,  may  be  held  responsible  for  certain  attacks  of 
extreme  dyspnoea  sometimes  experienced  by  subjects  of 
aortic  aneurism.  Associated  with  the  neutral  degenera- 
tion may  also  be  atrophy  of  the  left  abductor  muscle — 
the  crico.- arytenoid, — while  the  adductors — the  aryte- 
noids— remain  neatly  intact.  Constant  dyspnoea  is  more 
likely  to  be  due   to  direct  compression  of   the  trachea. 

How  shall  these  phenomena,  which  are,  also,  so  much 
like  those  of  a  laryngitis,  be  interpreted  as  due  to  aneu- 
rism rather  than  to  laryngitis,  in  the  absence  of  the 
physical  signs  of  aneurism? 

In  acute  laryngitis  we  have  often  the  cause — exposure 
to  cold — to  help  us  ;  in  chronic  we  have  not.     In  laryn- 


194  PH\'SICAL   DLA.GXOSIS. 

gitis  there  is  more  huskiness  and  less  of  stridor  in  the 
voice,  nor  is  the  cough  so  brassy,  or  the  voice  so  uni- 
formly changed ;  it  is  more  apt  to  alternate  with  normal 
voice.  In  aneurism  the  voice  grows  progressively  worse 
until  aphonia  results.  The  dyspncea  is  more  apt  to  be 
attended  with  wheezing,  and  is  sometimes  relieved  for  a 
time  by  coughing.  Stokes  called  attention  to  the  fact 
that  in  aneurism  the  stridor  of  the  voice  seems  to  come 
from  the  notch  of  the  sternum  rather  than  from  the 
larynx  itself.  In  aneurism  the  breathing  is  more  apt  to 
differ  in  the  two  lungs.  Then  we  have  the  laryngo- 
scopic  picture.  There  is  no  swelling  of  the  cords  in 
aneurism,  and  there  may  be  the  paralytic  phenomena 
detailed.  Finally,  in  laryngitis  there  is  apt  to  be 
fever. 

Then  there  is  the  tracheal  tugging  of  aneurism.  This 
is  a  dragging  downward  of  the  larynx  with  each  systole  of 
tne  heart.  The  patient  sits  with  his  head  slightly  thrown 
back  and  the  examiner,  standing  behind  him,  insinuates 
the  ends  of  the  fingers  under  the  edge  of  the  cricoid 
cartilage  and  gently  holds  it  up,  when  with  each  impulse 
the  larynx  is  pulled  downward.  It  is  said  that  it  may 
be  the  sole  sign  of  aneurism,  and  a  sign,  also,  that  the 
position  of  the  aneurism  is  such  as  to  involve  the  pos- 
terior aspect  of  the  arch.  It  is  said  never  to  be  present 
in  aneurism  of  the  innominate. 

Aneurism  of  the  arch  or  the  aorta  affects  the  pulse 
in  distal  arteries  chiefly  only  when  it  involves  the  origin 
of  blood-vessels  leading  to  those  arteries,  as  the  innomi- 
nate on  the  right  and  the  carotid  or  subclavian  on  the 


THORACIC    ANEURISM.  195 

left.  If  the  right  radial  pulse  is  enfeebled  or  delayed, 
the  aneurism  will  be  on  the  right,  involving  the  origin 
of  the  innominate ;  if  on  the  left,  involving  the  left 
carotid  or  subclavian.  Great  care  should  be  taken  in 
these  investigations,  and  they  should  be  made  from  the 
centre  to  the  periphery;  that  is,  the  carotids,  the  sub- 
clavians,  the  brachials,  and  the  radials  should  be  succes- 
sively examined  as  recommended  by  Sansom. 

These  effects  are  produced  by  the  aneurismal  sac, 
distorting  and  narrowing  the  orifice  of  the  vessel  by 
dragging  on  it ;  or  by  acting  as  the  elastic  air-chamber 
in  a  pump,  diminishing  thus  the  pulsatile  force  on 
vessels  beyond  it.  Osier  calls  attention  to  the  fact  that 
the  pulse  even  in  the  abdominal  aorta  and  its  branches 
may  be  thus  obliterated  by  a  large  thoracic  aneurism. 

Inequality  of  pupils  is  another  valuable  sign  of  aneurism 
of  the  thoracic  aorta,  due  to  the  involvement  of  the 
sympathetic,  its  organic  or  functional  destruction,  with 
resulting  paralysis  of  the  dilator  fibres  of  the  iris,  which 
is  thus  given  over  to  the  control  of  the  3d  nerve. 
Hence  the  pupil  is  contracted,  more  frequently  on  the 
left  side. 

Unilateral  sweating  is  similarly  caused. 

Aneurism  of  the  descending  aorta  below  the  arch, 
between  it  and  the  diaphragm,  has  its  most  constant 
symptom  in  pain — boring  pain— generally  due  to  intru 
sion  on  the  vertebrae,  and  any  persistent  boring  pain  in 
this  locality  should  suggest  a  thorough  examination. 
The  bruit,  more  apt  to  be  systolic  only,  is  often  not 
heard,  sometimes  faintly.     A  bulging  of  the  ribs  in  the 


196  PHYSICAL   DIAGNOSIS. 

posterior  thoracic   region  should  be  sought  for,   and  a 
dullness  on  percussion. 

ANEURISM   OF  THE    INNOMINATE. 

This  is  especially  indicated  by  its  murmur,  thrill, and 
an  impulse  in  the  vicinity  of  the  inner  end  of  the  right 
clavicle,  which  is  sometimes  raised  by  the  resulting 
tumor;  also  by  the  comparative  absence  of  signs  of 
pressure  on  the  larynx  or  oesophagus.  The  differences 
in  the  right  radial  pulse  alluded  to  are  especially  here 
present.  Tracheal  tugging  is  said  never  to  be  present 
in  aneurism  of  the  innominate. 

ANEURISM    OF  THE  SUBCLAVIAN. 

If  the  subclavian  is  invoked,  the  signs  are  further 
outward,  on  the  outer  side  of  the  sterno-cleido-mastoid. 
To  those  named  may  be  added  pressure  symptoms  upon 
the  subclavian  vein,  producing  swelling  of  the  arm  and 
neck;  upon  the  right  recurrent  laryngeal,  producing 
defective  speech  and  dyspnoea ;  on  the  sympathetic, 
producing  contraction  of  the  right  pupil,  and  on  the 
brachial  plexus  of  nerves,  pain.  Especially  would  these 
signs  point  to  aneurism  of  the  subclavian  if  the  pulse 
of  the  carotids  is  uninfluenced,  while  the  right  or  left 
radial  pulse  is. 

ANEURISM  OF  THE  PULMONARY  ARTERY. 

The  very  rare  condition  of  aneurism  of  the  pulmo- 
nary artery  may  produce  a  swelling,  with  the  other  local 


PHYSICAL    EXAMINATION    OF    THE    ABDOMEN.  1 97 

symptoms  described,  to  the  left  of  the  sternum,  in  the 
2d  interspace.  A  murmur -is  less  constant  and  is  not 
conducted  into  the  vessels  of  the  neck,  while  the  super- 
ficial pressure  signs  are  more  conspicuous.  There  is 
lividity  of  the  face  and  oedema,  and  the  dyspnoea  is 
naturally  very  great.  There  is  no  cough  or  voice  altera- 
tion. It  is  to  be  remembered,  too,  that  the  swelling  of 
an  aneurism  of  the  arch  of  the  aorta  may  extend  to  the 
left  of  the  sternum.  A  pulsating  empyema  in  this 
vicinity  in  my  experience  resembled  so  closely  a  pul- 
sating aneurism  that  I  feared  to  tap  it  until  suitable 
preliminary  exploration  was  made. 


PHYSICAL  EXAMINATION  OF  THE 
ABDOMEN. 

In  mapping  out  the  abdomen  for  the  study  of  the 
topography  of  its  organs  it  is  usual  to  divide  it  as  we  do 
the  thorax,  by  a  set  of  lines  which  apportion  it  into  nine 
regions.  First,  a  line  is  drawn  horizontally  around  the 
body  at  the  level  of  the  edge  of  the  thorax;  another 
at  the  level  of  the  crest  of  the  ilium.  Then  two  vertical 
lines  are  drawn  through  the  outer  end  of  the  cartilage 
of  the  8th  rib  above,  and  the  middle  of  Poupart's  liga- 
ment below.  The  abdominal  cavity  above  the  line 
drawn  around  the  edge  of  the  thorax  outside  of  the 
vertical  lines  forms  the  hypochondriac  region,  right  and 
left— th9.t  tinder  the  cartilages.    The  intermediate  region, 


198 


PHYSICAL    DLA.GNOSIS. 


is  the  epigastric.     The  others  are  sufficiently  indicated 
in  the  drawing;  from  Grav. 


Fig.  40. — Drawing  Showing  Regions  of  the  Abdomen. — {After  Gray.) 


The  following  table  of  the  viscera  contained  in  each 
of  the  regions  is  from  "  Gray's  Anatomy  "  : 


INSPECTION. 


199 


Right  Hypochondriac. 

The  right  lobe  of  hver 
and  the  gall-bladder, 
hepatic  flexure  of  the 
colon,  and  part  of  right 
kidney. 


Right  Lumbar. 
Ascending   colon,   part  of 
the    right    kidney,    and 
some  convolutions  of  the 
small  intestine. 


Right  Inguinal  (Iliac). 
The      caecum,      appendix 

caeci    (ureter,  spermatic 

vessels) . 


Epigastric  Region. 
The  middle  and  pyloric 
end  of  the  stomach, 
left  lobe  of  the  liver  and 
lobulus  spigelii,  the 
pancreas,  the  duode- 
num, parts  of  the  kid- 
neys, and  the  supra- 
renal capsules  (aorta 
and  branches,  vena 
cava,  semilunar  gan- 
glion, thoracic  duct). 


Umbilical  Region. 
The  transverse  colon, 
part  of  the  great  omen- 
tum and  mesentery, 
transverse  part  of  the 
duodenum,  and  some 
convolutions  of  the  je- 
junum and  ileum,  part 
of  both  kidneys  (and 
the  receptaculun 
chyli) . 


Hypogastric  Region. 

Convolutions  of  the  small 
intestine,  the  bladder 
in  children,  and  in 
the  adult  if  distended, 
and  the  uterus  dur- 
ing pregnancy  (often 
the  caecum,  appendix 
vermiformis,  and  sig- 
moid flexure  of  colon;. 


Left   Hypochondriac. 

The  splenic  end  of  the 
stomach,  the  spleen 
and  extremities  of  the 
pancreas,  the  splenic 
flexure  of  the  colon, 
and  part  of  the  left 
kidney. 


Left  lumbar. 
Descending  colon,  part 
of  the  omentum,  part 
of  the  left  kidney,  and 
some  convolutions  of 
the  small  intestine. 


Left  Inguinal  (Iliac). 
Sigmoid    flexure    oi    the 
colon    ( ureter,    sperm- 
atic vessels  . 


The  division  of  the  area  of  the  abdomen  into  four 
quadrants,  the  right  upper  and  lower  and  the  left  upper 
and  lower,  is  simple,  very  convenient,  and  for  most  pur- 
poses sufficiently  definite. 


INSPECTION. 


Inspection  notes  alterations  in  the  shape  of  the 
abdomen  from  distension  by  gases  or  dropsical  effu- 
sions, morbid  growths,  enlarged    organs  like   the   liver 


200  PHYSICAL   DUGNOSIS. 

and  spleen,  pregnancy,  distortions  due  to  positions 
necessitated  by  occupation  or  caused  by  tight  lacing. 
The  abdomen  of  the  little  child  and  that  of  the  man 
past  fifty  are  both  more  protuberant  than  that  at  an 
intermediate  age:  the  lower  or  pelvic  portion  of  the 
woman  is  broader  than  that  of  the  man.  There  is  in 
nature  quite  a  decided  difference  in  the  length  of  the 
waist  or  distance  between  the  lower  edge  of  the  thorax 
and  the  crest  of  the  ilia.  Apart  from  the  effect  of 
tight  lacing  in  women,  there  is  naturally  a  good  deal  of 
difference  in  the  width  of  their  waists.  In  lacing,  the 
pressure  is  generally  brought  to  bear  on  the  hypochon- 
driac and  the  epigastric  regions,  the  effect  of  which  is 
to  make  the  waist  appear  longer,  or  "  wasp-like."  After 
a  full  meal  the  upper  part  of  the  abdomen  is  fuller, 
l^ndue  enlargement  of  the  superficial  veins  is  some- 
times observed  in  inspecting  the  abdomen,  the  result  of 
obstruction  to  the  flojv  of  blood  in  the  portal  vein  or 
vena  cava.  Epigastric  pulsation  is  often  seen,  and  is 
commonly  of  no  significance,  though  occasionally  it  is 
due  to  aneurism  of  the  abdominal  aorta.  When  the 
abdominal  wall  is  very  thin  the  outline  of  certain  organs 
may  be  traced,  and  even  peristaltic  motions  in  the 
stomach  and  bowels  are  recognizable.  Through  such  an 
abdominal  wall  the  outline  of  an  enormously  distended 
stomach  may  even  be  recognized. 

The  patient  should  also  be  examined  in  the  knee- 
elbow  position,  which  will  permit  movable  tumors  to 
fall  forward  and  facilitate  their  recognition  by  inspec- 
tion as  well  as  by  palpation. 


PALPATION. 


PALPATION. 


Palpation  of  the  abdomen  should  be  practised  by 
laying  the  hand  flat  upon  the  abdomen  and  depressing 
the  ends  of  the  fingers  as  the  hand  is  moved  about, 
rather  than  by  "  poking "  with  the  fingers  of  the 
straight  hand  obliquely  placed.  The  abdominal  walls, 
too,  should  be  relaxed  by  semi-flexing  the  thighs  on 
the  abdomen,  and  the  legs  upon  the  thighs.  Thus  we 
learn  of  the  consistency  and  situation  of  various  organs 
and  abnormal  growths,  whether  they  are  smooth  or 
uneven,  whether  there  is  tenderness  or  tenseness.  In 
so  doing  the  degree  of  pressure  must  vary.  Some  pains 
are  relieved  by  pressure,  others  aggravated.  The  former 
are  more  apt  to  be  due  to  neuralgia  or  colic,  the  latter 
to  be  due  to  organic  causes. 

The  presence  of  fluid  may  be  settled  by  fluctuation, 
which  is  produced  by  placing  the  hand  on  one  side  in 
the  flank  and  tapping  the  other  side  gently  with  the 
fingers,  by  which  a  wave  is  produced  and  is  felt  by  the 
palpating  hand.  Our  knowledge  of  the  more  precise 
situation  of  fluid,  and  even  of  growths,  is  often  aided 
by  changing  the  position  of  the  patient.  Circumscribed 
fluctuation  may  sometimes  be  detected  in  hyatid  cysts 
of  the  liver,  ovarian  cysts,  and  rarely  cystic  kidneys. 
Sometimes  a  friction  or  roughness  can  be  felt  in  con- 
nection with  enlarged  liver  and  spleen. 

Under  favorable  circumstances  the  edge  of  the  liver 
and  even  the  end  of  the  gall-bladder  can  be  felt,  espe- 
cially if  the  latter  is  distended  with  bile  or  gall-stones, 


202  PHYSICAL   DIAGNOSIS. 

or  is  itself  the  seat  of  morbid  growths.  Especially  can 
the  liver  be  felt  if  it  is  much  enlaiged. 

Only  when  enlarged  can  the  spleen  be  felt  downward 
and  forward.  Eichhorst  gives  the  following  directions 
for  palpating  the  spleen  when  moderately  enlarged,  as 
in  typhoid  fever  :  Put  the  patient  in  the  right  diagonal 
position,  and  lay  the  finger  gently  between  the  anterior 
ends  of  the  nth  and  12th  ribs,  when  the  enlarged  spleen 
can  be  felt  with  almost  eveiy  deep  inspiration  in  spite  of 
meteotism. 

The  kidneys  are  too  deep-seated  to  be  felt  in  health. 
When  movable  or  floating,  the  right,  which  is  that 
almost  invariably  involved,  is  often  felt  more  toward 
the  median  line,  below  the  liver,  and  may  sometimes 
be  recognized  by  its  kidney  shape  and  easy  mobility, 
while  more  rarely  even  the  beating  of  the  renal  artery 
can  be  felt.  A  deep  inspiration  will  generally  cause 
such  a  kidney  to  move  downward.  Enlargements  of  the 
kidney  may  bring  the  organ  into  such  position  that  it 
can  be  felt  anteriorly.  Pressure  of  the  normal  kidney 
sometimes  gives  rise  to  a  peculiar  sickening  pain  like 
that  caused  by  bruising  the  testicle. 

The  pancreas  is  beyond  reach  in  health,  and  even 
when  the  subject  of  diseased  enlargement,  is  rarely  felt. 
Sometimes,  however,  between  the  right  mammillary  line 
and  the  median  line  and  behind  the  edge  of  the  liver 
can  be  felt  a  tumor  covered  by  intestine,  which  is  either 
the  enlarged  head  of  the  pancreas  or  a  part  of  the 
duodenum  with  adjacent  glands,  and  which,  if  asso- 
ciated with  jau7idice,  is  likely  to  be  a  tumor  or  cyst  of 


PALPATION. 


203 


the  pancreas.  A  tumor  of  the  pyloric  ofifice  of  the 
stomach,  also  commonly  higher  up  and  more  toward  the 
median  line,  is  characteri-.ed  by  its  greater  mobihty  and 
change  of  position  with  varying  degrees  of  distension  of 
the  stomach.  A  peculiar  rotary  motion  of  such  tumor 
is  characteristic. 

Only  under  the  most  unusual  conditions  can  enlarge- 
ments of  the  suprarenal  capsules  be  felt. 

Enlargements  of  the  mesenteric  glands  are  character- 
ized by  their  smoothness  and  mobility.  They  differ 
from  fecal  tumors,  which  may  often  be  felt  in  the  right 
groin,  by  the  softness  and  compressibility  of  the  latter 
and  their  gradually  forward  motion.  Only  after  great 
enlargement  do  the  deep-seated  or  posterior  abdominal 
glands  come  to  the  front,  uniting  with  the  more  super- 
ficial glands  to  form  large  tumors,  having  communicated 
to  them  the  impulse  of  the  aorta  from  behind. 

The  uterus  and  bladder,  always  behind  the  pubes, 
when  empty  and  noimal,  rise  as  palpable  central  tumors 
when  distended  by  their  physiological  contents,  whose 
distinctness  depends  largely  upon  the  thinness  of  the 
abdominal  walls,  and  is  much  more  accurately  investi- 
gated by  percussion. 

The  ovaries,  not  to  be  felt  in  health,  when  enlarged 
form  tumors  which  rise  up  from  the  pelvis  into  either 
flank,  and  thence  toward  the  centre  of  the  abdomen. 
When  their  contents  are  liquid,  circumscribed  fluctua- 
tion may  be  detected,  although  it  is  irregular  and  in- 
constant, and  there  is  this  difference  between  such 
liquid   and   liquid   free   in   the    abdominal   cavity — the 


204  Pm^SICAL    DLA. GNOSIS. 

latter  falls  away  into  the  flanks  as  the  patient  lies  down, 
while  the  ovarian  tumor  remains  central.  It  is  to  be 
remembered,  however,  that  there  may  be  tympany  in 
the  flanks  even  when  there  is  abdominal  dropsy,  when  the 
ascending  and  descending  colon  are  distended  with  gas, 
the  peritoneum  covering  them  lining  off  the  fluid. 

These  organs,  the  uterus  and  ovaries,  are,  however, 
even  more  satisfactorily  investigated  by  palpation 
through  the  vagina,  in  the  case  of  the  uterus  further 
aided  by  the  uterine  sound.  In  abdominal  dropsy  fluc- 
tuation may  also  be  detected  through  the  vagina,  less 
commonly  in  ovarian  cysts.  In  abdominal  dropsy  the 
uterus  is  not  usually  displaced  unless  simply  prolapsed ; 
in  ovarian  tumor  it  is  apt  to  be  displaced.  The  aortic 
impulse  is  sometmies  conveyed  to  an  ovarian  tumor, 
heaving  it  forward  wnth  each  pulse.  This  is  not  the 
case  in  an  abdominal  effusion. 

The  rectum  niar  be  similarly  explored,  the  hand 
being  sometimes  carried  far  up  into  it  after  careful  and 
gradual  dilatation  of  the  sphincters.  Rectal  exploration 
in  this  manner  should,  however,  be  cautiously  carried 
out,  as  it  is  possible  to  produce  rupture.  This  organ, 
as  well  as  the  uterus,  is  also  investigated  by  the  aid  of 
specula,  to  which  modern  invention  has  added  the  elec- 
tric light.     So,  too,  the  bladder  is  similarly  explored. 


PERCUSSION. 

Much  more  tangible  in  abdominal  investigation  are 
sometimes  the  results  of  percussion.     So  far  as  the  hypo- 


PERCUSSION.  205 

chondiiac,  epigastric,  and  even  lumbar  regions  are 
concerned,  the  normal  percussion  phenomena  have  been 
necessarily  detailed  under  thoracic  percussion,  which  see. 
For  abdominal  percussion  the  patient  should  be 
placed  in  a  relaxed  position,  like  that  described  for  pal- 
pation. A  pleximeter  is  here  conveniently  employed, 
and  the  force  of  the  blow  must  be  judicious  in  accord- 
ance with  the  viscera  to  be  investigated.  Thus,  if  stud}^- 
ing  the  lower  boundary  of  the  liver  or  spleen,  too  strong, 
a  blow  will  bring  out  the  tympany  of  adjacent  gas-con- 
taining viscera,  while  the  upper  borders  of  these  organs 
require  strong  percussion. 

Percussion  of  the  spleen  requires  some  special 
consideration.  Its  dull  sound  is  limited  by  the  resonance 
of  the  adjacent  lung  and  tympany  of  stomach  and  intes- 
tines, and  at  times  it  may  even  fail  of  detection.  It  may 
be  percussed  with  the  patient  standing  fully  stripped  or 
lying  on  the  right  side  with  the  legs  flexed.  Pretty  strong 
percussion  should  then  be  commenced  in  the  mid- 
axillary  line  from  the  axilla  downward  toward  the 
crest  of  the  ilium.  At  the  9th  rib,  usually,  sometimes 
a  little  lower,  in  health,  the  dull  sound  comes  out, 
associated  with  greater  resistance.  It  usually  continues 
downward  as  far  as  the  nth  rib  or  a  little  below,  where 
it  is  replaced  by  the  tympany  of  the  intestine.  The 
anterior  boundary  of  the  spleen  is  determined  by  per- 
cussing backward  of  a  line  drawn  downward  from  the 
anterior  fold  of  the  axilla.  The  spleen  is  seldom  found 
anterior  to  the  midaxillary  line  in  health.  Posteriorly 
the  splenic  dullness  is  not  separable  from  that  of  the 


2o6  PHYSICAL   DUGXOSIS. 

left  kidney.  Abnormal  enlargements  of  the  speen 
are  downward  and  anteriorly  and  may  reach  colossal 
proportions. 

The  percussion  borders  of  the  kidneys  have  already 
been  outlined  on  page  52. 

Of  the  remaining  abdominal  organs  the  stotnach  and 
i?itestines  alone  approach  the  surface  in  health  in  such 
way  as  to  make  their  limitation  possible  by  percussion. 

They  require  also  some  delicacy  in  discrimination  of 
shades  of  sound,  more  particularly  in  pitch.  The 
quality  met  in  percussing  these  organs  is,  for  the  most 
part,  tympanitic,  and  it  is  chiefly  variations  in  the 
pitch  of  the  tympany  which  are  to  be  discriminated. 
The  same  organ  may  exhibit  different  degrees  of  pitch 
under  different  conditions.  Thus,  the  stomach  when 
moderately  distended  with  gas  gives  a  low-pitched  tym- 
panitic sound  when  percussed  ;  when  more  distended 
it  gives  a  higher  pitch ;  when  more  distended  still  it 
may  give  a  dull  sound.  (See  p.  43.)  Given  the  stom- 
ach and  intestine  in  an  equal  degree  of  tension,  the 
stomach  will  respond  to  percussion  with  a  lower-pitched 
tympany  than  the  intestine,  because  it  is  a  larger  cavity. 
This  is  sometimes  spoken  of  as  less  tympanitic;  some- 
times the  stomach  percussion  note  is  ringing,  amphoric, 
echoing.  By  means  of  these  differences  when  present 
we  can  distinguish  one  hollow  organ  from  another. 
Again,  the  presence  of  liquids  or  solids  in  the  stomach 
influences  the  percussion  note. 

The  hollow  viscera  en  masse  can  be  mapped  out  by 
determining  the  boundaries    of    the    solid    viscera  just 


PERCUSSION.  207 

described.  But  we  want  to  do  more  than  this.  Below 
this  line  is  the  tympany  of  the  whole  abdominal  cavity. 
We  want  to  separate  one  hollow  organ  from  another — 
the  stomach  from  the  small  intestine,  the  small  intestine 
from  the  large.  For  this  the  patient  must  be  recum- 
bent. As  stated,  the  stomach  tympany  is  ordinarily 
lower  pitched  than  bowel  tympany.  Bearing  this  in 
mind,  we  can  generally  determine  the  stomach  bounda- 
ries when  the  organ  is  not  overdistended  with  liquid, 
gas,  or  food.  The  upper  border  of  the  stomach,  as 
recognizable  by  percussion,  corresponds  with  the  lower 
edge  of  the  liver  and  inner  border  of  the  spleen,  as 
above  outlined.  To  the  left  of  the  apex  of  the  heart 
the  stomach  tympany  is  mixed  with  the  resonance  of 
the  lung.  At  this  point,  about  the  7th  rib,  is  the 
cardiac  end  of  the  stomach.  Percussing  downward 
from  these  boundaries,  we  are  generally  able  to  find  a 
difference  of  note — a  higher  pitch,  a  purer  tympany, 
belonging  to  the  transverse  colon — bounded  by  a  curved 
line  which  crosses  the  left  edge  of  the  thorax  at  about 
the  inner  end  of  the  loth  rib,  the  median  line  just 
above  the  umbilicus,  and  thence  upward  to  the  edge  of 
the  hver  to  the  right  of  the  median  line.  This  is  the 
boundaiy  of  the  greater  curvature  of  the  stomach,  and 
includes  between  it  and  the  upper  border  alluded  to  a 
hand-breadth  space  called  by  Traube  the  half  moon  space 
of  the  stomach  tympany,  better  termed  crescentic 
shape.  Leichtenstern  has  applied  the  name  pulmono- 
hepatic  angle  to  the  point  of  junction  between 
the  lower  edge  of  the  left  lobe  of  the  liver  and  the  lower 


2  08  PHA'SICAL   DMGNOSIS. 

border  of  the  left  lung.  The  tip  of  this  angle  is 
behind  the  6th  rib  just  below  the  apex  seat,  and  is 
bisected  b}'  the  pleural  angle,  which,  it  will  be  remem- 
bered, is  not  filled  by  the  lung  except  in  deep  inspira- 
tion. This  is  the  highest  part  of  the  chest-wall  reached 
by  the  stomach,  and  it  is  a  point  pretty  constantly 
maintained. 

The  half-moon  tympanitic  space  may  be  converted 
into  one  of  percussion  dulness  by  filling  the  stomach 
with  food,  or  the  line  of  demarcation  may  be  made 
more  distinct  by  having  the  patient  drink  a  glass  of 
water  just  before  the  examination  ;  or,  as  originally 
suggested  by  Frerichs,  by  taking  in  rapid  succession  the 
two  portions  of  a  Seidlitz  powder, — tartaric  acid  and 
sodium  bicarbonate.  The  gas  thus  Hberated  rapidly 
distends  the  stomach  even  be3'ond  the  limits  described. 
The  normal  limit  of  the  lower  curvature  may,  however, 
be  put  above  the  umbilicus,  although  it  cannot  be  said 
to  be  abnormally  low  when  at  the  umbilicus,  an  event 
not  unusual  after  fifty  years  of  age.  In  men  the  greater 
cur\-ature  is  not  quite  as  low  as  in  women,  and  in  work- 
ing-women not  so  low  as  in  others.  When  the  lower 
curvature  is  much  below  the  umbilicus  the  stomach  may 
be  said  to  be  dilated. 

As  stated,  the  percussion  note  of  the  hiTge  intestine 
is  higher  pitched  and  more  purely  tympanitic  than  that 
usual  to  the  stomach.  When  containing  faeces  it  is 
rendered  duller,  and  in  consequence  of  this  fact  there 
is  often  less  resonance  in  the  left  iliac  fossa  than  in  the 
right,  although  faeces  may  also  accumulate  in  the  latter. 


AUSCULTATION.  209 

and  an  impaction  in  the  head  of  the  colon  give  positive 
dulness.  The  colon  may  also  be  artificially  distended 
with  gas,  for  examination,  if  desired. 

The  percussion  note  of  the  small  intestine  is  still  higher 
pitched  than  that  of  the  large,  and  by  this  it  may  be 
distinguished  from  that  bowel,  if  not  filled  with  solid 
matter  or  liquid.  The  differences  in  percussion  note 
alluded  to  are  not  always  equally  marked,  and  it  is  not 
always  possible,  in  consequence,  to  demark  the  organs. 

The  bladder  is  recognizable  by  its  dull  note  above  the 
pubis  when  distended  with  urine. 

It  remains  to  make  some  allusion  to  peculiarities  in 
the  percussion  of  ovarian  cysts  with  fluid  contents, 
as  compared  with  dropsical  effusions  into  the  abdomen. 
In  the  former,  the  percussion  note  is  dull  in  the  central 
abdominal  region,  while  in  the  flanks  there  is  apt  to  be 
tympanitic  percussion,  from  the  fact  that  the  intestines 
are  pushed  into  them.  With  change  of  position,  the 
dulness  in  ovarian  dropsy  does  not  change  position, 
while  in  abdominal  dropsies  it  does. 

The  two  may,  however,  be  combined,  when  the  diffi- 
culty is  increased,  and  a  preliminary  tapping  may  be 
necessary  to  settle  the  question. 


AUSCULTATION. 

Auscultation,  of  all  the  means  of  physical  diagnosis, 
gives  us  least  information  in  abdominal  investigation. 
An  aneurism   may  furnish  a   murmur  over   the  aorta, 


2IO  PHYSICAL   DIAGNOSIS. 

and  sometimes  a  murmur  may  be  heard  in  an  enlarged 
spleen,  and  even  a  friction  sound  may  be  heard.  Bor- 
borygnii  are  sometimes  audible  at  a  distance  ;  also  nre- 
tallic  tinkling  from  the  splashing  of  fluid  in  a  distended 
stomach. 

Certain  deglutition  sounds  are  described  by  Ewald. 
First  there  is  a  deglution  murmur,  with  which  all  are 
familiar,  produced  by  swallowing  a  mouthful  of  liquid, 
propagated  from  the  pharynx  into  the  oesophagus,  and 
heard  all  along  the  latter  tube.  It  has  no  diagnostic 
significance. 

In  addition  are  heard,  only  near  the  cardia,  during 
deglutition,  two  murmurs.  The  best  site  for  auscul- 
tating them  is  just  below  the  xiphoid  cartilage.  The 
first,  ox  hissing  inui-mur  (^Durchspritzgerdiisch'),  qcq.wx% 
almost  immediately  after  the  beginning  of  deglutition, 
and  sounds  as  if  fluid  was  being  directly  squirted 
through  a  tube  containing  air.  The  second  sound,  or 
pressure  murmur  {Durchpressgej'dusch~),  is  heard  from  six 
to  twelve  seconds  later,  and  described  by  Ewald  as  a 
series  of  tones  rapidly  following  one  another, — either 
"  gurgling,  clucking,  splashing,  or  sprinkling." 

These  two  sounds  alternate.  The  first  is  heard  infre- 
quently, and  is  said  to  indicate  a  relaxation  of  the 
cardiac  orifice.  The  second  sound  is  quite  frequent, 
and  is  absent  only  when  the  first  is  heard.  Its  cause  is 
not  precisely  determined,  being  ascribed  by  some  to 
audible  vibrations  of  the  cardiac  orifice,  caused  by  the 
passage  of  food  over  it ;  by  others  to  a  "  pressing 
through  "  of  air  swallowed  with  the  food. 


AUSCULTATION.  2 1  T 

It  is  on  the  absence,  therefore,  of  the  second  murmur 
that  diagnostic  value  depends ;  /.  e..  it  is  apt  to  be 
wanting  in  obstructive  disease  of  the  cardiac  orifice, 
although  too  much  stress  must  not  be  laid  on  this  sign, 
since  the  murmur  is  not  invariably  present  in  health. 

Splashing  or  succussion  sounds  are  heard  when  the 
stomach  is  filled  partly  with  air  and  partly  with  water. 
It  is  produced  by  tapping  the  lateral  region  adjacent  to 
the  stomach,  and  may  often  be  produced  by  the  patient 
himself  by  shaking  the  body.  It  is  abnormal  only 
when  heard  at  a  time  when  there  should  be  no  liquid  in 
the  stomach,  as,  for  example,  long  after-  taking  food.  It 
is  especially  common  at  such  time  in  dilatation  of  the 
stomach.  A  like  sound  may  rarely  be  produced  under 
like  conditions  in  the  colon. 

Borborygmi,  or  "  grumbling "  noises  occur  in  the 
stomach  and  bowels  when  distended  with  gas. 

Heart  sounds  and  breathing  sounds  are  often  intensi- 
fied by  a  stomach  distended  with  gas,  becoming  ring- 
ing or  amphoric. 


212  PHYSICAL   DLVGNOSIS. 

EXAMINATION  OF  BLOOD. 

The  examination  of  blood  for  ordinan^  purposes  need 
include  only :  (i)  The  ordinary  microscopic  examina- 
tion of  fresh  blood.  (2)  The  counting  of  the  cor- 
puscles, red  and  white.  (3)  Measuring  of  haemoglobin. 
(4)   The  preparation  of  stained  films. 

THE  ORDINARY  MICROSCOPIC  EXAMINATION. 
(cj)  Place  a  drop  of  blood  from  the  cleansed  finger  or 
ear  on  a  slide  and  drop  the  cover  on  without  pressing. 
If  the  layer  of  blood  be  too  thick,  a  fresh  slide  should 
be  made.  (/')  Note  the  formation  of  rouleaux,  less 
prone  to  occur  when  the  number  of  red  discs  is  small. 
(/)  Note  the  leucocytes  isolated  in  the  open  spaces 
between  the  rouleaux.  (//)  Note  abnormality  of  size 
{mcga/ocyfcs  and  microcytes')  and  shape  (J'oikiiocyfcs'). 
The  varieties  of  leucocytes  are  studied  in  the  stained 
preparations  to  be  described.  (<?)  Look  for  abnormal 
elements  including  pigment  granules,  malarial  organ- 
isms, filarise.  The  malarial  parasite  requires  a  yV  ini- 
mersion,  and  the  slide  should  be  studied  for  at  least  half 
an  hour. 

THE  COUNTING  OF   BLOOD   CORPUSCLES. 
Decidedly  the  most  convenient  instrument  for  esti- 
mating the  number  of  corpuscles  to  the  cubic  millimeter 
is  the  cytometer  of  Thoma-Zeiss.     The  directions  for  its 
use  appended  are  essentially  those  of  Zeiss — the  maker. 


Al 


AZ 


A3 


BZ 

0(Jo 


oi@.0 


Dl 


DZ 


El 


EZ 


0^ 


£3 


£4 
1^ 


FI 


yi^'^fs. 


Gl 


HI 

m 


HZ 


H4 


Illustrating  Different  Forms  of  the  Malarial  Organisms  with  their  Stages  of 
Development. — {From  Tyson's  "  Practice  of  Medicine") 

Al,  A.J,  A3,  A^.  Sporulation stage-  B^,  Bn.  Sporules  separating.  Cx,  C«.  Freesporules.  D^,  D^. 
Epi-corpuscular  forms.  E^,  En,  E^,  E^.  Intra-corpuscular  forms.  Ei,  E^.  The  large  extra- 
corpuscular  body.  Ci,  Go.  The  flagellate  forms.  H^,  H<i,  H^,  H^,  H^,  H^.  The  crescent-shaped 
parasite  and  its  developmental  changes  in  shape. 


THE    COUNTING    OF    BLOOD    CORPUSCLES.  213 

The  apparatus  consists  of  the  following  parts  : 
(i)   A  graduated  pipette  with  india-rubber  tubing  and 
mouth-piece.      (Fig.  41.) 

(2)  A  divided  cell  upon  an  oblong  shp.      (Fig.  42,) 

(3)  A  cover- glass  with  plane-ground  surfaces. 

(4)  A  diluting  fluid.  Numerous  diluting  fluids  have 
been  suggested.  A  very  convenient  one  is  a  .8  per  cent, 
solution  of  common  salt  filtered.  Gowers'  fluid  is  a  very 
good  one.  It  consists  of  sulphate  of  soda,  6.3  gm. ; 
acetic  acid,  :^.6  gm. ;  distilled  water,  117.0  gm.* 

In  order  to  count  the  red  corpuscles  of  human  blood, 
the  tip  of  any  finger,  or,  better,  the  lobe  of  the  ear,  is 
cleaned  with  water  and  alcohol,  and  then  rubbed  between 
the  fingers  of  the  other  hand.  A  slight  arterial  hyper- 
semia  will  arise,  so  that  a  faidy  deep  puncture  with  a 
lancet-like  needle  is  sufficient  to  cause  a  drop  of  blood 
to  appear.  The  point  of  the  pipette  is  quickly  placed  into 
it  and  the  blood  sucked  in  up  to  division  r.  Then  the 
point  of  the  pipette  is  cleaned  from  the  blood  sticking  to 
it  by  a  cloth  kept  ready  for  the  purpose,  and  plunged  into 
the  diluting  fluid,  which  is  sucked  up  into  the  spherical 


*  Toison's  fluid  may  be  used.  It  has  the  advantage  of  staining 
the  white  corpuscles,  but  it  is  more  difficult  to  cleanse  a  tube  stained 
with  it.     It  is  made  as  follows: 

Distilled  water,      160  c.c. 

Neutral  glycerine, ^o  c.c. 

Sodium  sulphate  pur., 8  gm. 


Sodium  chloride, 


I  gm. 


Methyl-violet,  5   B, 0.025  g 

Mix  and  filter  before  using. 


214 


PHYSICAL   DIAGNOSIS. 


enlargement  of  the  pipette.  As  soon  as  the  sphere  is 
filled  up  to  division  loi,  the  sucking  is  discontinued 
and  the  mouth-piece  of  the  india-rubber  tube  closed 
by  putting  the  finger  upon  it.  The 
contents  of  the  spherical  enlargement 
are  now  to  be  mixed  by  thorough 
shaking.  Thus  in  this  sphere  99  parts 
by  volume  of  the  solution  are  mixed 
with  one  part  by  volume  of  blood,  or 
100  parts  by  volume  of  the  mixture 
contain  one  part  by  volume  of  blood, 
for  the  fluid  in  the  capillary  tube  does 
not  enter  into  the  mixture. 

If  the  blood  is  drawn  in  up  to 
a  lower  division,  say  0.5,  instead  of 
division  i,  then  with  the  same  mode 
of  proceeding  another  dilution  is  ob- 
tained, viz.,  I  :  200. 

Mterward,  by  blowing  air  into  the 
india-rubber  tubing,  the  diluting  solu- 
tion is  removed  from  the  capillar}'  part 
of  the  tube.     The   next   drop  of   the 
mixture  is  emptied  upon  the  middle  of 
the  bottom  of  the  divided  cell,  after 
Ihe  latter  has  been  carefully  cleansed. 
The  cover-glass  is  immediately  placed 
over   it,   and    the   apparatus   is   trans- 
ferred to  the  horizontal  stage  of  the  microscope  and  left 
standing  quietly  for  some  minutes,  so   that  the   blood 
corpuscles  may  settle  down. 


Fig.  41. — H/EMOCYTO- 
METER  Pipette. — 
( Thoma-Zeiss. ) 


THE  COUNTING  OF  BLOOD  CORPUSCLES.      215 

It  is  necessary  for  a  successful  enumeration  that  the 
divided  cell  and  cover-glass  should  be  thoroughly 
cleaned.  If  this  is  done  properly  the  Newtonian  rings 
will  be  perceived  along  the  edge  of  the  cover-glass  as 
far  as  it  rests  upon  the  wall  of  the  cell,  and  this  indicates 
that  the  cover-glass  lies  well  upon  it.  At  the  same  time 
it  must  be  seen  that  no  fluid  enters  between  the  cover- 
glass  ancT  the  wall  of  the  cell.  On  the  contrary,  the 
drop  of  blood  should  be  placed  in  the  centre  of  the 
cell,  and  spread  thence  to  fill  up  the  space  between  the 


Fig.  42. — Thoma-Zeiss  Counting  Slide. 
s.  Slide      m.  Platform,     c.  Wall  of  trench. 

cover-glass  and  the  bottom  of  the  cell  for  some  square 
millimeters. 

Special  care  should  be  taken  to  keep  the  pipette  in 
clean  condition.  Every  time  after  use  it  should  be 
rinsed  with  (i)  the  diluting  fluid,  (2)  distilled  water, 
(3)  absolute  alcohol,  and  (4)  ether.  If  dust  or  coagu- 
lated blood-should  still  stick  to  the  pipette,  it  should  be 
removed  with  strong  acids  or  alkalies  by  repeated  rins- 
ings, assisted,  if  necessary,  by  a  bristle. 

The  corpuscles  may  be  counted  by  any  object  glass 
magnifying  about  300  diameters. 

Every  fifth  square  of  each  horizontal  and  vertical  row 
of  squares  is  crossed  by  an  additional  line  to  facilitate 
the  counting.     Each   square  occupies  an   area  of  ^^ 


2l6 


PHYSICAL   DL4.GN0SIS. 


sq.  mm.,  and  above  each  square  there  is  a  space  of  ^qqq 
c.  mm.,  since  the  distance  of  the  bottom  of  the  cell  from 
the  lower  surface  of  the  cover-glass  amounts  exactly  to 
jL  mm.  The  corpuscles  which  first  were  suspended  in 
this  space  have  now  settled  and  are  lying  on  the  bottom 
of  the  cell,  where  they  may  be  counted  The  corpus- 
cles lying  upon  the  lines  should  be  counted,  but,  of 
course,  only  once.     Thus,   all    corpuscles  lying  on  the 


" 

r°  -' 

'i  °'': 

-T-ir^ 

:*;; 

^ 

.•-{ 

.'  ='.'' 

%°'° 

.'  • ;  '.  i  ■ 

=  .• 

» °  =  A 

•'  ; .  \ 

»»% 

.•,•.  .=  = 

".■. 

"^   "o        o' 

>:.\ 

\°': 

•  , 

'»' 

:-i-: 

°  •  = 

'  =  '<>! 

{ \\ 

]: 

;-; 

\°  - 

V  'i'  / 

=;■"= 

■ »'  •  ' 

V  :•'.  ■ 

"  J 

'.'o  i,'" 

' ' 

?} 

».'  ■: 

.»■!.'.' 

.',!  • 

.%;. 

=  0  o    % 

'  ;  '  ■  .  '. 

-■U 

=v."  .'" 

" , 

''4-: 

Fig.  43. — Group  of  16  Small  Squares,  each  of  a  capacity  of  jtrtct.  c.  mm.  mak- 
ing one  large  square  of  the  Thoma-Zeiss  cj'tometer,  magnified. 


horizontal  lines  should  be  counted  in  the  squares  above 
them,  and  all  corpuscles  lying  on  the  vertical  hnes 
should  be  counted  in  the  squares  to  the  right  of  them. 
The  calculation  is  as  follows  :  If  by  a  dilution  of  the 
blood  in  the  proportion  of  i  :  a,  z  corpuscles  have  been 
counted  in  ;/  squares,  then 

I  c.  mm.  of  undiluted  blood  ^=  4000  X  — — —  blood    corpuscles. 

n 


THE    COUNTING   OF    BLOOD    CORPUSCLES. 


217 


If,  for  example,  by  a  dilution  of  the  blood  in  the  pro- 
portion of  I  :  100,  as  we  supposed  above,  in  200  squares 
altogether  2570  red  blood  corpuscles  were  found,  then 
the  calculation  will  give  for  i  c.  mm.  of  blood — 


4000  X  100  X  2570  _  5^j4o^ooo  blood  corpuscles. 
200 


For    counting   the   white   Mood  corpuscles   a  pipette 
should  be  used  which  allows  a  dilution  in  the  propor- 


r^ 


Fig.  44. — Thoma-Zeiss  Ruled  Slide,  focussed  for  lo  and  12  squares  to  cover 
exactly  the  field  of  view  of  the  microscope. 


tion  of  I  :  lo,  or  i  :  20,  and  instead  of  the  salt  solution 
an  aqueous  .5  per  cent,  solution  of  acetic  acid,  to  which 
may  be  added  a  little  methyl-violet,  should  be  chosen 
for  diluting.  The  red  corpuscles  will  disappear  in  this 
fluid,  but  the  white  ones  will  remain  and  are  easily 
counted.  The  easiest  method  of  calculation  is  to  de- 
termine the  cubic  contents  of  the  space  covered  by  the 
field  of  the  microscope  and  to  count  the  leucocytes  in 


2l8  PHYSICAL    DIAGNOSIS. 

a  large  number  of  such  fields.  ]\Iove  the  tube  of  the 
microscope  up  and  down  until  one  of  the  parallel  lines 
of  the  ruled  slide  corresponds  with  the  edge  of  the  cir- 
cular field  of  vision,  as  at  a,  b  (Fig.  44).  Then,  as  each 
square  is  Jq-  mm.  wide,  the  whole  diameter  of  the  field 
equals  -^-^^  multiplied  by  the  number  of  squares  included 
between  the  parallel  lines.  Thus  if  the  number  be  10, 
the  diameter  is  \^  or  }^  mm.,  the  radius  ^4 ,  and  the  area 
of  the  circle  {^%Y  X  3-i4i6;  the  cubic  contents  iYxY 
or  yL  X  3-1416  X  y\j-  ,  (yq^  mm.,  being  the  depth  of  the 
space)  ;  /.  e.,  ^l^l^  =  -V  ^-  ^^^^^^-  ^  ^^^  capacity  of 
the  field  of  vision. 

A  number  of  fields  are  counted,  say  10,  containing  in 
all  200  leucocytes,  making  the  average  of  each  field  20. 
But  as  the  capacity  of  one  field  is  Jj-  c.  mm.,  an  entire 
c.  mm.  would  contain  10x51  =  51  o-  Now,  as  the  blood 
is  supposed  to  have  been  diluted  20  times,  the  actual 
number  of  leucocytes  per  c.  nim.  would  be  10,200. 
Hence,  for  a  field  of  to  squares,  10  fields  being  counted, 
we  need  simply  to  multiply  the  average  of  one  field  by 
51  and  20,  or  1020.  Calculations  for  fields  of  five,  six, 
or  any  convenient  number  of  squares  may  be  made. 

Studies  by  Thoma  and  others,  with  a  view  to  deter- 
mining possible  errors  with  the  instrument  whose  use 
has  thus  been  described,  go  to  show  the  constant  errors 
to  be  insignificant,  less  than  one  per  cent.,  while  the 
accidental  and  variable  errors,  which  are  unavoidable, 
diminish  with  the  number  of  corpuscles  counted.  Thus, 
by  counting  200  red  corpuscles  they  amount  to  five  per 
cent,  of  the  total  result,  by  counting  — 


THE    COUNTING    OF    BLOOD    CORPUSCLES.  219 

1,250  corpuscles  amount  to  2  per  cent,  of  the  total. 
5,000  "  "  I    "       "  "  " 

20,000  "  "  ^2    "       "  "  " 

At  least  four  sets  of  i6,  or  64  squares,  should  be 
counted  in  estimating  red  corpuscles.  To  count  the 
whole  256  such  squares  takes  about  one-half  hour,  and 
usually  means  from  1200  to  1500  corpuscles. 

Estimating  the  Corpuscles  by  the  Centrifuge. 

In  1885,  Professor  Blix,  of  Upsala,  Sweden,  sug- 
gested the  use  of  centrifugal  force  in  estimating  the 
volume  of  red  blood  corpuscles,  and  Dr.  S.  G.  Heden 
has  devised  an  instrument  called  the  hcematokrit  for  this 
purpose.  Dr.  Judson  Daland  has  further  improved  this 
instrument  so  that  after  the  blood,  diluted  with  an 
equal  bulk  of  a  2.5  per  cent,  solution  of  bichromate  of 
potash,  has  received  the  requisite  amount  of  rotation, 
the  percentage  volume  of  red  corpuscles  may  be  read  off 
from  the  cylindrical  tubes  in  which  the  blood  is  placed, 
and  from  this  deduced  the  number  in  each  cubic  milli- 
meter by  simply  adding  five  ciphers  to  the  reading. 

Dr.  Daland  regards  the  hsematokrit  as  both  more 
speedy  and  more  accurate  than  the  cytometer,  basing 
his  conclusions  on  a  very  large  number  of  comparative 
observations.  He  used  also  a  great  variety  of  fluids  for 
dilution,  and  concluded  that  the  2.5  per  cent,  solution  of 
bichromate  of  potash  is,  for  many  reasons,  the  best. 
The  hsematokrit  also  enables  one  to  measure  the  volume 
of  colorless  blood  corpuscles,  but  no  method  has  yet 
been  devised  for  calculating  their  number. 


2  20  PHYSICAL    DIAGNOSIS. 

TO   MEASURE  HEMOGLOBIN. 

Such  estimation  is,  of  course,  approximate.     The  best 
instrument   for  this   i)urpose  is   the  hi^moglobinometer 


Fig.  45. — H.BMOGLOBINOMETER   OF  FlEISCHL. 

of  Fleischl.     It  consists  of  a  stage  perforated  by  a  central 
opening,  below  which  is  a  gypsum  reflector,  .S",  by  which 


TO    MEASURE    HEMOGLOBIN.  221 

the  light  from  a  candle  may  be  thrown  directly  into  the 
opening.  Into  the  latter  is  fitted  a  cylinder,  G,  divided 
by  a  partition  into  two  equal  parts,  one-half  a,  being 
over  the  unobstructed  opening,  the  other,  a\  over  a 
wedge-shaped  piece  of  glass  interposed  between  it  and 
the  opening.  The  glass  is  colored  with  Cassius'  gold 
purple,  and  presents,  of  course,  a  gradually  increasing 
depth  of  color  in  passing  from  the  thinner  to  the 
thicker  end.  The  wedge  of  glass  is  movable  by  a  rack 
and  pinion  alongside  of  a  scale  graduated  in  loo  equal 
parts,  of  which  the  figure  lOO  corresponds  with  the 
depth  of  color  of  a  mixture  of  normal  blood,  and 
lower  figures  correspond  with  that  of  thinner  blood. 
The  examination  should  be  made  in  a  cool,  dark 
room. 

To  use  the  instrument  each  demi-cylinder  is  filled 
with  water,  and  into  the  one  a,  opposite  the  tmobstructed 
opening  is  put  a  quantity  of  blood,  measured  in  the 
little  cylinder  shown  in  the  cut.  In  order  to  prevent 
oxidation,  the  mixing  vessel  should  be  covered  with  the 
round  cover-glass  supplied  with  the  hsemometer.  It 
should  be  applied  from  that  side  containing  the  water. 
If  applied  from  the  other  side  some  of  the  blood  might 
be  carried  into  the  clear  water  and  thus  spoil  the 
examination.  The  wedge  of  glass  is  then  moved  along 
by  the  milled  head,  T,  until  the  color  of  the  blood 
solution  exactly  coincides  with  the  color  of  the  opposite 
half  cylinder  containing  water  only,  but  placed  over 
the  colored  glass.  The  figure  attained  on  the  scale 
when  the  shades  are  identical  indicates  the  percentage 


222  PHYSICAL    DIAGNOSIS. 

of  haemoglobin.  In  point  of  fact,  it  rarely  happens 
that  a  normal  blood  exceeds  ninety  per  cent.,  a  fact 
which  should  be  borne  in  mind. 

Dr.  Daland  has  suggested  covering  the  entire  cylinder 
when  ready  for  use  by  a  cap  containing  a  central  slit 
%  inch  (6  mm.)  wide  over  the  centre,  through  which 
the  examination  can  be  made  with  greater  facility  than 
with  the  entire  cylinder  exposed. 


PREPARATION   OF  STAINED  FILMS. 

The  staining  of  the  blood  preparations  for  clinical 
pui poses  may  be  rapidly  performed  by  the  following 
methods  : 

Blood  films  are  prepared  by  cleansing  the  finger  or 
the  lobe  of  the  ear  carefully  with  alcohol ;  pricking  it 
gently,  wiping  away'the  first  few  drops  that  emerge,  and 
then  touching  the  top  of  a  small  drop  with  a  clean 
cover-glass,  placing  upon  another  equally  clean  cover- 
glass  and  sliding  the  two  apart.  The  film  dries  in  the  air 
quickly  and  may  be  kept  indefinitely.  Fixation  may  be 
accomplished  by  immersing  the  cover-glass  in  a  mixture 
of  equal  parts  of  absolute  alcohol  and  ether,  for  from 
three  minutes  to  one-half  hour.  In  rapid  clinical  work 
staining  with  eosin  and  hgematoxylin  gives  satisfactory 
pictures  of  the  morphology  of  the  corpuscles.  The 
cover-glass  fixed  and  dried  is  stained  wnth  a  one  per  cent, 
solution  of  eosin  (soluble  in  water)  in  sixty  per  cent, 
alcohol  for  one  or   two   minutes.     It   is   then   counter- 


^^,  /^      CT"^ 


J^t's:.  /.—Normal   Blood.     Fixed  bs'  heat- 
ing, stained  with  Erlich's  triple  stain. 

a.  Normal  polymorphous  leucocytes. 

b.  Lymphocyte. 

c.  Large  mononuclear  leucocyte. 

d.  Eosinophile. 

e.  Red  Corpuscles. 


Fig.  2. — LiENO  Medullary  LEUK.E.VIIA.  Fixed 
by  heating,  stained  with  Erlich's  acid 
fuchsia,  methyl  green,  orange  O  mixture. 

a.  Normal  polymorphous  leucocytes. 

b.  Erlich's  myelocyte,  neutrophilic. 

c.  Small  myelocyte. 

d.  Eosinophile. 

e.  Red  Corpuscles. 

f.  Nucleated  red  corpuscle. 


FIO.    8. 


'9 


^*%. 


^   , 
^   i 


Fig.  J.— NORM.A.L  Blood.  Fixed  in  abso- 
lute alcohol-ether,  stained  with  Eosin 
and  Hematoxylin. 

a.  Polymorphous  leucocytes. 

b.  Lymphocyte. 

c.  Large  mononuclear  leucoc5'te. 

d.  Eosinophile. 

e.  Red  Corpuscles. 


PREPARATION   OF   STAINED    FILMS.  223 

stained  with  Delafield's  *  hsematoxylin  for  from  one-half 
to  one  minute.  The  specimen  is  then  washed,  dried, 
and  mounted.  The  red  corpuscles  take  the  eosin 
(pink)  as  do  also  the  eosinophile  granules,  but  nuclei 
of  the  white  corpuscles  are  stained  blue  with  the  hsema- 
toxylin. 

Simultaneous  staining  and  counterstaining  may  be 
obtained  by  Gollasch's  mixture  : 

Eosin,     •    •    • 0.5 

H£ematoxylin, 2.0 

Glycerine, 
Distilled  water, 

Al)solute  alcohol,  of  each, 100. o 

Glacial  acetic  acid, 10. o 

Alum — slight  excess. 

This  solution  requires  several  weeks  for  ripening. 
The  blood  films  after,  fixation  are  stained  for  several 
minutes  and  then  washed,  dried,  and  mounted. 

For    the    demonstration    of     the    eosinophilic    and 

*  Delafield''s  Hematoxylin  is  made  of  hsematoxylin  crystals,  4 
grams;  95  per  cent,  alcohol,  25  c.  c;  saturated  aqueous  solution 
of  ammonia  alum,  400  c.  c. 

Add  the  hsematoxylin  dissolved  in  the  alcohol  to  the  alum  solu- 
tion, and  expose  the  mixture  in  an  unstoppered  bottle  to  the  light 
and  air  for  from  three  to  four  days.  Filter  and  add  glycerine,  100 
c.  c;   95  per  cent,  alcohol,  100  c.  c. 

Allow  the  solution  to  stand  in  the  light  until  sufficiently  dark, 
then  filter  and  keep  in  a  tightly  stoppered  bottle.  It  keeps  well 
and  maintains  a  purplish  tinge  as  long  as  it  is  good. 


2  24  PHYSICAL    DIAGNOSIS. 

neutrophilic  granulations  as  well  as  the  general  morph- 
ology, Ehrlich's  triple  stain  is  used.     This  consists  of — 

Saturated  aqueous  solution  orange  G.,  .    .  120  to  135 
"  "  "       acid  fuchsin,    .     80  to  165 

"  "  "       methyl-green,  125 

Add— 

Water, 300 

Absolute  alcohol, 200 

Glycerine, 100 

Frequently  a  little  more  methyl-green  is  required,  and 
the  solution  must  generally  be  tested  and  corrected  by 
the  addition  of  one  or  other  stain  after  each  prepara- 
tion. 

-  Staining  with  the  triple  stain  is  most  satisfactory  after 
previous  heating  of  the  blood  films  for  fixation ;  they 
may  be  baked  in  a  hot  oven  at  110°  or  120°  C.  for  an 
hour,  or  with  some  experience  .  the  heating  is  readily 
carried  out  by  passing  the  specimen  through  the  flame, 
as  in  staining  sputum. 

The  Widal  Test  for  Typhoid  Fever  —This 
depends  on  the  power  inherent  in  the  serum  of  a  person 
who  has  had  typhoid  fever  a  variable  but  generally  short 
time,  of  causing  living  typhoid  bacilli  to  cease  their 
active  movements,  and  to  form  clumps.  These  changes 
take  place  in  from  a  few  minutes  to  an  hour  after  the 
contact  has  been  brought  about. 

The  test  is  practised  as  follows:  The  finger  or  ear 
lobe  is  thoroughly  sterilized  and  punctured  with  a 
sterile  lancet,   and   the  blood   drawn  into   a  sterilized 


PREPARATION    OF   STAINED    FILMS.  225 

pipette,  which  is  then  sealed  up.  A  drop  of  diltite 
bouillon  culture  of  typhoid  bacilli,  not  more  than  twenty- 
four  hours  old,  is  placed  on  a  sterilized  slide.  To  this  add 
a  minute  quantity  of  the  serum  from  the  pipette,  mix 
rapidly,  apply  the  sterilized  cover-glass  and  press  it  gently 
to  obtain  a  uniform  film,  and  examine  with  a  power  of 
300  to  400  diameters.  Uninfluenced  by  the  specific 
serum  the  bacilli  maintain  active  movement  for  a  long 
time — days  if  the  specimen  be  properly  prepared — and 
exhibit  no  tendency  to  form  clumps.  Under  the  in- 
fluence of  the  typhoid  serum  the  movement  promptly 
ceases  and  the  clump  formation  takes  place.  The  re- 
action is  more  frequent  after  the  first  week,  but  may  take 
place  as  early  as  the  third  or  fourth  day. 

Instead  of  the  serum  a  drop  of  dried  blood  may  be 
mixed  with  distilled  water  and  used  instead  of  serum 
with  the  same  result.  The  bacillus  culture  is  commonly 
obtained  from  the  spleen  of  one  dead  of  typhoid. 


226  PHYSICAL   DLAGNOSIS. 

EXAMINATION    OF   SPUTUM. 

The  coarse  examination  of  sputum  includes  the 
coarser  examination  for  quantity,  color,  consistence, 
shape,  and  odor.  The  minute  examination  seeks  bacilli, 
cellular  elements,  including  blood  and  eosinophile  cells, 
elastic  fibres,  Curschmann's  spirals,  and  Charcot-Leyden 
cr}'stals. 

The  eosinophile  cells  are  .large  and  contain  numerous 
fine  granules  stainable  with  eosin.  They  are  often 
found  in  asthma,  where  they  may  be  associated  with 
Charcot-Leyden  crystals,  minute  acicular  or  spmdle- 
shaped  bodies. 

Curschmauii's  spirals  also  occur  in  the  sputum  of 
asthma.  They  are  large  enough  to  be  seen  by  the  naked 
eye,  looking  like  sago  grains.  When  unrolled  they 
appear  as  convoluted  threads  which  may  be  an  inch 
long.  Under  the  microscope  they  are  found  made  of  a 
central  thread,  about  which  clings  a  coating  of  tough 
mucus  containing  mucous  corpuscles. 

Previous  to  the  discovery  of  the  tubercle  bacillus, 
elastic  fibres  were  the  most  distinctive  objects  found  in 
sputum.  They  are  found  where  there  has  been  break- 
ing down  of  the  lung  from  gangrene,  tuberculosis,  or 
abscess.  They  are  best  sought  by  boiling  suspected 
sputum  with  several  times  its  bulk  of  liquor  sodse,  or 
potassae,  by  which  the  former  is  thinned  and  the  fibres 
fall  to  the  bottom  of  the  test-tube  or  conical  glass,  whence 
they  may  be  raised  with  a  pipette.  Good  examples  fur- 
nish circular  forms  derived  from  the  alveoli  of  the  lungs. 


STAINING    OF    TUBERCLE    BACILLI.  227 

STAINING  OF  TUBERCLE   BACILLI. 

Of  the  various  methods  of  staining  tubercle  bacilli 
that  by  the  carbol  fuchsin  solution  of  Ziehl-Neelsen, 
with  or  without  Gabbetfs  counter-stain  of  methyl  blue, 
appears  to  stand  the  test  of  time  as  well,  if  not  better 
than  any  other.  By  this  method  the  bacillus  takes  a 
bright  red  color  from  the  fuchsin,  the  mordant  being 
carbolic  acid. 

The  carbol-fitchsin  solution  is  made  as  follows  : 

Powdered  fuchsin, I  part 

Alcohol,     .... 10  parts 

Five  per  cent,  solution  carbolic  acid,     .    .    .  100  parts 
Mix  and  filter. 
^The  older  the  solution  the  better. 

Two  methods  are  practised  with  this  staining  fluid,  a 
rapid  and  a  slow,  the  former  being  more  commonly 
practised  for  diagnostic  purposes. 

I.  The  rapid  method  with  carbol-fuchsin  ivithotit  or 
with  counter-stain  by  methylene  blue.  A  very  small 
clump  of  the  moist  solid  part  of  the  sputum  mass  is 
selected  and  brought  with  forceps  or  platinum  loop  on 
a  clean  cover-glass.  Upon  this  another  cover-glass  is 
superimposed  and  the  two  are  pressed  and  rubbed  over 
each  other  until  the  specimen  is  thoroughly  smeared  over 
both.  They  are  then  separated  and  two  specimens  are 
thus  obtained.  When  dry,  one  of  these  covers  is  passed, 
specimen  side  up,  three  times  slowly  over  the  flame  of 
a  spirit  lamp  or  Bun  sen  burner,  by  which  the  albumin 


2  28  PHYSICAL   DIAGNOSIS. 

is  coagulated  and  the  specimen  fixed.  The  specimen  is 
then  completely  covered  with  the  staining  fluid  and 
held  over  the  flame  until  the  solution  begins  to  vaporize, 
care  being  taken  to  keep  all  parts  of  the  glass  thoroughly 
covered  with  the  stain,  but  not  allowed  to  boil.  This  is 
kept  up  for  one  minute,  when  it  is  washed  in  water  for  two 
or  three  seconds.  It  is  then  decolorized  in  acidulated 
alcohol,  eight  or  ten  drops  of  HCl  or  five  drops  HNO3 
to  a  watch  cr}'stal  of  alcohol,  and  examined  in  the  latter 
solution,  by  a  one-twelfth  oil-immersion  and  Abba's 
condenser,  although  a  little  experience  with  a  dry  lens 
of  350  diameters  or  higher  will  soon  lead  to  the  recog- 
nition of  the  bacilli,  which  are  stained  a  handsome  red. 
The  preparation  is  more  brilliant  and  its  study  rather 
less  tr}dng  to  the  eyes  if  counter-stained  by  Gabbe^tt's 
acid  blue,  composed  of — 

Methylene  blue,      2  parts 

Twenty-five  per  cent,  solution  sulphuric  acid,  100  parts 

After  being  washed  in  water,  the  specimen  is  immersed 
for  about  thirty  seconds  in  the  acid  blue,  washed  off  in 
water,  dried  between  filtering  paper,  and  examined  in 
water. 

2.  Slower  method  with  ca^-bol-fiichsin,  and  counter- 
stai7i  with  Gabbetfs  acid  blue.  This  slower  rnethod  is 
always  more  satisfactory  if  time  permits,  and  should 
alone  be  used  for  permanent  preparations. 

The  steps  are  the  same  until  the  staining  stage  is 
reached,  when  the  cover-glasses  containing    the  speci- 


THE   PNEUMOCOCCUS.  229 

men  are  placed  in  the  carbol-fuchsin  solution,  say  at  five 
or  six  o'clock  in  the  evening,  and  allowed  to  remain 
until  next  morning.  They  are  then  washed  in  water, 
counter-stained  by  Gabbett's  acid-blue  solution,  again 
washed  in  water,  dried  between  filtering  paper,  and 
studied  in  water,  or  if  it  is  desired  to  mount  the  speci- 
men permanently,  it  is  passed  through  alcohol  or  xylol 
into  Canada  balsam.  Oil  of  cloves  should  not  be  used 
for  clearing,  as  it  sometimes  declorizes  the  stained 
specimen.  Nor  should  specimens  stained  in  aniline 
colors  be  mounted  in  glycerin,  as  this  gradually  with- 
draws the  stain. 

The  bacillus  may  be  stained  by  Gram's  method. 
Sections  are  treated  similarly  by  the  slow  method  and 
mounted  in  balsam. 

Dr.  C.  W.  Purdy  has  devised  a  "  beater  "  with  which 
to  beat  up  the  sputum  mixed  in  a  two-ounce  glass 
graduate  with  equal  parts  of  a  three  per  cent,  salt 
solution  for  a  moment  or  two,  after  which  he  puts  the 
fluid  into  the  centrifuge.  The  sediment  thus  obtained 
is  then  stained  and  studied. 


THE  PNEUMOCOCCUS. 

The  micrococcus  lanceolatus  or  diplococcus  pneu- 
vionice,  the  true  bacillus  of  pneumonia,  was  discovered 
independently  by  Surgeon  General  Sternberg,  U.  S.  A., 
in  1 88 1,  and  by  Pasteur  somewhat  later.  The  latter  was 
the  first  to  publish  an  account  of  it.  Neither  appre- 
ciated its  relation  to  croupous  pneumonia.     This  Tala- 


230  PHYSICAL   DLV GNOSIS. 

moil  first  asserted  in  1S83.  The  subject  was  first  satis- 
factorily cleared  up  by  Frae'nkel  and  ^Veichselbaunl  in 
1886,  whence  it  is  also  associated  with  their  names. 

The  piiciimococciis  is  characterized  by  its  lance-shape 
and  capsulation  as  found  in  tissues  and  sputum.  In 
cultures  it  is  without  capsule.  Found  most  frequently 
in  the  lung  in  croupous  pneumonia,  it  also  occurs  in  the 
sputum  of  pneumonia,  in  fresh  endocardial  vegetations, 
and  the  pus  of  cerebro-spinal  meningitis.  It  usually 
occurs  in  pairs— diplococci — sometimes  in  filaments  of 
three  or  four  elements. 

The  simplest  extemporaneous  stain  is  the  carbol- 
fuchsin  solution  (p.  227).  An  immersion  of  a  few 
minutes  usually  suffices,  when  the  coccus  itself  will  have 
become  intensely  red,  while  the  capsule  has  assumed  a 
light  reddish  tint.  The  capsule  may  also  be  stained  in 
the  same  way  as  that  of  Friedlander's  bacillus  described 
below. 

The  diplococcus  puci/jiionice  may  also  be  stained  by 
Gram's  metliod,  as  follows  : 

I .  The  cover-glass  preparation  is  i)laced  for  from  two 
to  five  minutes  in  warm  Ehrlich-  Weigerfs  saturated 
aniline  solution  of  gentian  violet.* 

*  Aniline  oil, 4  parts 

Distilled  water,        100  parts 

Shake,  filter  through  moist  filter  and  then 
add — Saturated  alcoholic  solution  (stain, 
10   grams;    absolute  alcohol,  40  grams), 

gentian  violet,  or  methyl-blue, 11  parts 

Filter. 


THE    PNEUMOCOCCUS.  23  I 

2.  Transfer  directly  without  washing  into  Gram's 
solution  (iodine,  t,  iodide  of  potass.  2,  water  300)  for 
from  two  to  three  minutes,  where  it  becomes  quite  black. 

3.  Wash  in  absolute  alcohol  until  the  primary  black 
color  becomes  pale  gray.  All  the  cellular  elements  are 
decolorized  except  the  micro-organism,  which  has 
assumed  a  deep  blackish  blue. 

4.  Mount  in  Canada  balsam. 

This  method  is  particularly  valuable  in  the  differential 
diagnosis  between  the  diplococcus  and  the — 

' Pncunw-bacillus  of  Friedldnder. — -This  bacillus  is 
oval,  encapsulated,  and  occurs,  also,  in  pairs,  and  is 
sometimes  found  in  the  lung  of   croupous  pneumonia. 

It  is  also  stainable  in  aqueous  staining  solutions  as  the 
bacillus  of  Fraenkel-Weichselbaum,  the  capsule  remain- 
ing unstained.     //  cannot  be  stained  by  Gramas  method. 

To  stain  the  capsule  in  cover-glass  preparations, 
Friedlander  directs  : 

1.  The  prepared  cover-glass,  drawn  three  times 
through  the  flame,  is  placed  in  one  per  cent,  acetic  acid 
solution  for  two  minutes. 

2.  Remove  the  acetic  acid  by  blowing  on  the  cover- 
glass  through  a  pointed  glass  tube,  and  allow  to  dry  in 
the  air. 

3.  Stain  for  ten  seconds  in  saturated  aniline-water- 
gentian-violet  solution. 

4.  Wash  in  water,  dry  between  filter  paper,  mount  in 
balsam. 

For  sections  : 

I.  Stain   for   twenty-four  hours  in  warmth  in  a  solu- 


232  PHYSICAL   DL4GN0SIS. 

tion  composed  of  concentrated  *  alcoholic  gentian- 
violet  solution  50,  distilled  water  100,  glacial  acetic 
acid  10. 

2.  Wash  in  one  per  cent,  acetic  acid  solution. 

3.  In  alcohol  to  dehydrate. 

4.  Mount  in  balsam. 

Bacillus  of  Diphtheria. — The  short  curved  bacil- 
lus assigned  by  Loffler  as  the  cause  of  diphtheria  is  well 
stained  by  Loffler's  alkaline  methylene  blue  solution  of — 

Concentrated  alcoholic  solution  methyl-blue 

(1:40),  .  30  c.  c. 

Caustic  potash  (i:  10,000), lOO  c.  c. 

Another  specimen  should  be  stained  by  Neisser's 
method,  which  consists  in  staining  for  from  one-half 
to  one  minute  in  a  solution  consisting  of  one  gram  of 
Grlibler's  methylene  blue  dissolved  in  20  c.  c.  of  90  per 
cent,  alcohol  and  then  added  to  960  c.  c.  of  distilled 
water  and  50  c.  c.  glacial  acetic  acid. 

After  staining  in  the  blue  mixture  they  are  washed  off 
in  water,  and  are  then  stained  for  from  three  to  five 
seconds  in  a  solution  consisting  of  two  grams  of  vesuvin 
(Bismarck  brown)  dissolved  in  one  litre  of  boiling  dis- 
tilled water  and  filtered.  They  are  then  again  washed 
off  in  water  and  are  ready  for  examination. 

The  object  of  these  duplicate  examinations  is  this  : 
By  the  ordinary  Loffler  method  of  staining  there  are 
occasionally  encountered  micro-organisms  that  are  mor- 

*Ten  grams  of  the  powdered  dye,  40  grams  absolute  alcohol. 


THE   PNEUMOCOCCUS.  233 

phologically  strikingly  suggestive  of  the  diphtheria 
bacillus.  When,  however,  these  micro-organisms  are  sub- 
jected to  the  Neisser  stain,  the  difference  between  them 
and  the  genuine  diphtheria  bacillus  is,  in  the  vast  majority 
of  instances,  very  manifest.  This  difference  consists  in 
the  appearance  in  the  true  diphtheria  bacillus  of  minute 
granules  or  spheres  that  take  on  the  blue  stain  very 
heavily,  looking  almost  black,  and  show  very  con- 
spicuously in  the  brown  counter-stain  to  which  the 
micro-organisms  have  been  subjected.  These  granules 
do  not  appear  in  the  organisms  that  are  not  true  diph- 
theria bacilli, — at 'least  when  they  do,  it  is  so  rare  as  to 
be  extremely  exceptional.  This  method  of  duplicate 
preparation  is  greatly  superior  to  the  methods  hitherto 
used,  since  the  Neisser  stain  controls  the  ordinary  ex- 
amination with  the  Lofifler  stain. 

The  Lofifler  bacillus  may  also  be  stained  by  Gram's 
method  (p.  230). 

Slides  made  from  the  false  membrane  are  seldom 
satisfactory,  because  it  is  seldom  that  a  pure  infection 
exists.  Cultures  should  be  made,  which  should  be  eight 
to  fifteen  hours  old,  and  in  order  that  the  Neisser  stain 
may  give  the  best  results,  the  culture  should  not  be  older 
nor  younger  than  about  fifteen  hours,  and  should  not 
have  been  cultivated  at  a  greater  temperature  than  35° 
to  36°  C. 

The  typhoid  bacillus  is  stained  by  Lofifler's  solu- 
tion. //  is  not  stainable  by  Grant's  method.  It  may  be 
obtained  from  the  spleen  and  from  the  blood  in  rose- 
colored  spots. 


234  PHYSICAL   DLA.GNOSIS. 

The  cholera  bacillus  is  stained  in  the  concen- 
trated aqueous  solutions  of  fuchsin  ;  sections  by  fuchsin 
solutions  or  methyl-blue.  A  flocculent  mass  from  a 
stool  is  treated  between  glass  covers  and  dried  and  fixed 
as  in  the  case  ot  sputum.  //  is  not  stained  by  Gramas 
method. 

Bacillus  of  Syphilis. — DeGiaconus  method.  The 
cover-glass  preparations  made  from  the  pus  are  warmed 
for  a  few  minutes  in  the  aniline-water  fuchsin  solution 
then  washed  in  water  to  which  a  few  drops  of  a  chloride 
of  iron  solution  have  been  added,  and  decolorized  in  a 
concentrated  solution  of  chloride  of  iron.  They  are 
finally  washed  and  studied  in  water.  The  syphilis 
bacillus  remains  red,  while  all  other  cells  are  decolorized. 
If  desired  to  mount,  dehydrate  rapidly  in  absolute 
alcohol,  clarify  in  xylol  and  mount  in  Canada  balsam. 

The  gonococcus  is  very  well  stained  by  the  carbol- 
fuchsin  method  already  described  for  the  tubercle  bacil 
lus.     The    true    gonococcus    is   not   stained  by  Gram's 
method.     It  is  thus  distinguished  from  similar  microbes. 


EXAMINATION   OF    GASTRIC    CONTENTS.  235 

CHEMICAL  EXAMINATION  OF  GAS- 
TRIC CONTENTS. 

A  variety  of  test-meals  has  been  suggested,  the  pro- 
ducts of  whose  digestion  are  submitted  to  examination. 
The  test  breakfast  of  Ewald  is  usually  preferred  on 
account  of  its  simplicity,  convenience,  comparative 
cleanliness,  and  easy  manipulation.  It  consists  of  an 
ordinary  dry  roll,*  weighing  35  grams  (a  little  more 
than  an  ounce),  and  300  c.  c.  (10  ounces)  of  either 
warm  water  or  weak  tea  without  milk  or  sugar.  The 
Ewald  meal  contains  no  lactic  acid,  or,  if  any,  so 
small  a  quantity  that  it  does  not  respond  to  the  ordi- 
nary tests.  The  meal  is  given  after  fasting  all  night, 
or  after  washing  out  the  stomach.  The  stomach  should 
be  first  washed  out  under  any  circumstances  if  there  is 
reason  to  believe  any  residue  is  left  from  a  previous 
meal.  The  Leube  meal,  which  may  be  regarded  as  a 
full  meal,  the  Ewald  being  a  light  meal,  consists  of  soup- 
meat  and  bread,  and  contains  consideiable  lactic  acid. 

One  hour  after  the  ingestion  of  the  Ewald  meal  the 
product  is  removed  by  the  flexible  stomach  tube.  The 
tube  is  sufficiently  lubricated  by  dipping  it  into  warm 
water,  after  which  it  is  introduced  by  carrying  the  end 
well   back   into   the   pharynx  and  directing  the  patient 


*  Such  a  roll  containing  about  35  per  cent,  of  water,  7  per  cent, 
of  albumen,  5  per  cent,  of  fat,  4  per  cent,  of  sugar,  52.5  per  cent, 
of  non-nitrogenous  extractive  substances,  and  i  per  cent,  of  ash, 
includes,  therefore,  the  usual  elements  of  a  mixed  diet. 


236  PHYSICAL    DIAGNOSIS, 

to  s^A'allo^v  as  it  is  gently  pushed  downward.  The  tube 
should  be  about  95  centimetres  (37^2  inches)  long. 
From  the  fundus  of  the  stomach  to  the  incisor  teeth  is 
60  to  65  centimetres  (23.5  to  25.5  inches),  and  about 
this  much  should  be  taken  up  when  the  tube  is  well  in 
place.  The  Ewald  tube  is  usually  marked  at  this  place. 
A  long  tube  allows  the  stomach  to  be  emptied  by 
siphonage  after  a  little  pressure  on  the  abdomen  has 
been  exerted  to  start  the  motion  of  the  contents ;  or 
they  may  be  removed  by  aspiration.  The  amount  with- 
drawn, which  should  be  about  40  c.  c,  is  first  examined 
macropcopically  as  to  quantity,  color,  and  consistence, 
minutely  for  blood  or  other  abnormal  constituents,  then 
filtered  after  previous  thorough  shaking,  in  order  to 
diffuse  uniformly  the  acid  constituents. 

In  healthful  conditions  the  gastric  contents  are  acid 
in  ten  or  fifteen  minutes  after  food  ingestion,  the  acidity 
depending  on  free  acids  or  acid  salts.  The  secretion  of 
hydrochloric  acid  begins  immediately,  the  first  secreted 
combining  with  the  native  proteids  and  mineral  salts, 
forming  acid  proteids  and  acid  salts.  The  latter, 
chiefly  acid  phosphates  (HjKPO^)  form  in  the  gastric 
contents  by  the  action  of  HCl  upon  the  phosphates 
(HK2PO4)  contained  in  the  food.  As  soon  as  the 
affinities  of  these  substances  are  satisfied,  free  HCl 
makes  its  appearance.  Free  HCl  appears  in  from  15  to 
20  minutes  after  the  ingestion  of  an  Ewald  meal;  in 
from  25  to  30  minutes  after  ingestion  of  twice  as  much; 
in  from  25  to  35  minutes  after  the  ingestion  of  60  gm. 
meat;   60  to  90  minutes  after  egg  albumen  ;  45  minutes 


EXAMINATION    OF    GASTRIC    CONTENTS.  237 

after  a  mixed  meal  of  bread,  meat,  and  vegetables.  Fat 
and  potato  delay  the  appearance  of  HCl.  It  gradually 
increases  in  amount  until  at  the  acme  of  digestion  the 
free  HCl  reaches,  after  a  light  meal,  .05  to  .19  per 
cent.,  and  .2  to  .33  per  cent,  after  an  abundant  meal. 
The  maximum  is  reached  in  one  and  a  half  to  two  hours 
after  a  light  meal,  and  two  to  three  hours  after  a  full  meal. 
Lactic  acid  is  not  secreted  by  the  stomach  ;  if  present, 
it  has  either  been  introduced  with  food  or  is  the  lesult 
of  abnormal  fermentation  of  food  ingested. 

The  procedure  is  as  follows  with  the  filtered  fluid  : 

1.  Test  reaction  with  litmus  or  Congo  red  paper, 
the  former  being  rendered  red,  the  latter  blue  by  acids. 

2.  Test  for  free  acid  and  acid  salts  qualita- 
tively. See  also  p.  246.  This  may  be  done  roughly  by 
means  of  the  aniline  dyes  Congo  red  and  tropaoline  00 — 
r orange  Poirier  of  the  French.  A  saturated  watery  or 
alcoholic  solution  is  made,  strips  of  filtered  paper  dipped 
into  such  solution,  dried,  and  thus  preserved  for  use. 
The  paper  is,  however,  less  delicate  than  the  solution, 
which  in  the  case  of  Congo  red,  strikes  a  beautiful  sky- 
blue  reaction  with  a  solution  containing  but  0.02  per  1000 
of  HCl.  A  purple  color  is  produced  by  organic  acids, 
and  a  dull  brown  with  acid  salts.  Combined  acids  do 
not  affect  the  color. 

The  tropseolin  solution  is  dark  yellowish  red,  and  a 
solution  of  free  acid,  as  HCl,  0.025  fo  1000,  changes  it 
to  a  deep  dark  brown.  It  is  slightly  less  delicate, 
therefore,  than    the  Congo   red.     Acid  salts,    as    acid 


238  PHYSICAL   DIAGNOSIS. 

sodium  phosphate,  make  if  straiu-yellow.  In  all  of  these 
tests  it  is  necessary  to  use  an  Excess  of  the  fluid  to  be 
tested.  This  is  accomplished  by  placing  five  or  ten 
drops  of  the  reagent  in.  a  test  glass  or  porcelain  capsule 
and  adding  one  to  two  cubic  centimetres  (15  to  30 
d?-ops)  of  the  filtered  contents.  Tolerably  delicate  tests 
can  thus  be  made,  though  their  delicacy  is  affected  by 
acid  salts  and  albuminoids,  especially  albumose  and 
peptones. 

Leo^s  carbonate  of  calciujti  test  is  based  upon  the  fact 
that  CaOCOs  in  cold  solution  7ieutralizes  free  acids 
ojily,  not  reacting  with  acid  salts.  A  strip  of  blue 
litmus  paper  having  been  previously  moistened  with 
the  filtrate  as  a  standard,  a  few"  drops  of  the  latter  are 
thoroughly  mixed  in  a  watch-glass  with  a  small  amount 
of  chemically  pure  powdered  calcium  carbonate.  After 
the  complete  neutralization  of  the  free  acids  and  dis- 
appearance of  the  separated  CO2,  the  reaction  is  tested 
with  another  piece  of  litmus  and  the  result  compared 
with  the  standard.  If  the  litmus  is  no  longer  reddened 
the  acidity  was  due  to  free  acids  only,  while  if  there  is 
still  redness,  but  less  in  degree  than  that  of  the  standard, 
theie  are  both  free  acids  and  acid  salts. 

3.  Test  for  free  Hydrochoric  Acid  — Gilnz- 
burg^s  test  is  commonly  used,  or  if  the  result  is  negative 
or  doubtful  with  it,  Boas's  test. 

Giinzburg's  solution  is  made  as  follows : 

Phloroglucin,    . 2  parts  (gr.  xxx) 

Vanillin, i  part  (gr.  xv) 

Absolute  alcohol, 30  parts  (fjj) 


EXAMINATION    OF    GASTRIC    CONTENTS.  239 

The  solution  is  pale  yellow  and  has  a  decided  odor  of 
vanilla.  On  exposure  to  light  it  assumes  a  dark  golden 
yellow,  and  it  must  therefore  be  kept  in  dark  hued 
bottles  or  be  freshly  made  as  required. 

A  drop  or  two  of  the  reagent  is  placed  on  a  porce- 
lain plate  or  capsule  with  an  equal  quantity  of  the 
gastric  filtrate,  and  a  gentle  heat  applied,  not  to  boil, 
but  simply  to  evaporate.  Very  soon  a  beautiful  rose- 
red  tinge  will  appear  at  the  edge  of  the  mixture,or 
red  stripes  will  be  observed.  Blowing  at  the  edge  will 
favor  the  appearance  of  the  red  stripes.  This  test  is 
unmistakable,  and  surpasses  all  others  in  delicacy,  being 
available  when  HCl  is  present  in  the  proportion  of  i  to 
20,000,  or  .05  per  mille.  Filtration  of  the  gastric 
contents  is  not  necessary. 

Boasts  test  is  based  upon  the  fact  that  resorcin  strikes 
a  similar  reaction  with  hydrochloric  acid.  The  solution 
consists  of — 

Resublimed  resorcin, 5  parts  (gr.  Ixxv) 

■      White  sugar, 3     "     (gr.  xlv) 

Dilute  alcohol, 100     "      (f^iiiss) 

Three  to  five  drops  of  the  reagent  are  poured  into  a 
porcelain  dish  and  an  equal  quantity  of  stomach  con- 
tents added.  Heat  is  applied  as  in  Giinzburg's  test, 
and  a  purple-red  color  appears  at  the  edge  of  the  drop. 
It  is  said  also  to  detect  .05  per  mille  of  HCl. 

Neither  of  these  tests  responds  to  the  organic  acids  or 
is  interfered  with  by  peptones  or  acid  salts. 

Topfefs  test  consists  in  the  addition  of  one  drop  of  a 


240  PHYSICAL   DIAGNOSIS. 

half  per  cent,  alcoholic  solution  of  dimethyl-amido- 
azo-benzol  to  a  portion  of  the  contents  in  a  test-tube. 
If  HCl  is  present  a  carmine-red  color  results. 

Free  HCl  may  also  be  sought  by  Leo's  test  after  ex- 
tracting the  fatty  acids  by  heat  and  the  lactic  acid  by 
ether,  when  the  fre  acid  remaining  will  only  be  HCl,  of 
which,  according  to  Leo,  .02  per  1000  may  be  detected 
if  decided  amounts  of  acid  phosphates  are  not  present, 
and  even  then  .008  per  cent. 

4.  Test  for  Organic  Acids. — These  include  lactic 
acid  and  the  true  fatty  acids,  especially  butyric.  They 
are  not  normal  secretions,  but  in  the  early  stage  of 
digestion  are  not  necessarily  abnormal  constituents, 
as  they  may  be  ingested  with  food.  This  is  especially 
true  of  lactic  and  acetic.  Commonly,  if  detectable 
by  the  ordinary  reagents,  they  are  pathological.  Abnor- 
mal lactic  acid  is  formed  by  fermentation  of  carbo- 
hydrate foods  by  action  of  bacteria,  probably  more  than 
one.  Butyric  acid  is  also  formed  from  carbohydrate 
and  milk  foods  by  the  action  of  bacilli.  Acetic  acid 
has  a  like  origin  through  the  action  of  the  mycoderma 
aceti. 

Uffehnanii' s  Test. — Lactic  acid  is  recognized  by  its 
effect  upon  a  very  dilute,  almost  colorless,  solution  of 
neutral  ferric  chloride,  which  is  converted  into  a  canary- 
yellow  color  by  its  action.  This  is  Uffelmann's  test. 
It  is  rendered  more  certain  when  a  few  drops  of  a  neutral 
ferric  chloride  solution  are  mixed  with  one  or  two  drops 
of  pure  carbolic  acid,  and  adding  water  until  the  solu- 
tion assumes  an  amethyst  blue  color.     A   few  dops  of 


EXAMINATION    OF    GASTRIC    CONTENTS.  24 1 

even  a  .05  per  mille  solution  of  lactic  acid  (i  in  20,000) 
will  change  the  blue  to  the  distinctive  yellow  color. 

There  are,  however,  sources  of  error.  The  lactates 
cause  the  same  reaction,  but  this  matters  not,  because 
we  desire  to  recognize  the  lactic  acid,  whether  in  com- 
bination or  not.  The  reaction,  however,  takes  place 
with  alcohol,  sugar,  and  certain  salts,  especially  phos- 
phates, which  are  often  found  in  gastric  contents.  The 
color  produced  by  phosphates  is  not  identical,  but  if  the 
filtrate  operated  with  has  a  yellow  tinge  the  resulting 
color  may  approximate  very  closely.  Under  these  cir- 
cumstances the  lactic  acid  must  be  extracted  with  ether. 
To  five  c.  c.  of  the  stomach  contents  add  two  drops  of 
strong  hydrochloric  acid.  Heat  the  mixture  to  a  syrupy 
consistence  over  a  flame  or  water-bath.  Shake  the  resi- 
due thoroughly  with  three  or  four  times  the  amount  of 
ether.  The  ether  is  allowed  to  rise  on  top,  which  it  does 
rapidly,  and  is  then  poured  off  into  a  glass  beaker.  More 
ether  is  added  and  the  washing  repeated,  until  in  all 
about  30  c.  c.  (f§j)of  ether  have  been  us^d.  The  ether 
is  then  evaporated  by  placing  the  beaker,  with  its  con- 
tents, in  a  vessel  of  hot  water.  The  residue  is  redissolved 
in  a  few  drops  of  water  and  one  or  two  drops  of  Uffel- 
mann's  reagent  allowed  to  fall  from  a  pipette  into  the 
solution.  Too  much  of  the  solution  may  mask  the 
reaction.  This  test  is  much  more  delicate  than  tro- 
paeoline,  which  may  fail  to  show  a  reaction  for  free  acid 
because  of  its  concealment  by  acid  salts. 
■  The  fatty  acids,  especially  hityric,  strike  a  tawny  yel- 
low color  with  a  reddish  tinge  with  Uffelmann's  chloride 


242  Pm^SICAL   DIAGNOSIS. 

of    iron    solution,    but  .5    per    1000    or    i  in    2000    is 
required  before  the  reaction  occurs. 

Fatty  acids  may  also  be  detected  by  heating  to  the 
boiling  point  a  few  c.  c.  of  the  gastric  filtrate  in  a  test- 
tube,  over  the  mouth  of  which  a  strip  of  moistened 
neutral  or  blue  litmus  paper  is  placed.  On  this  the 
vaporized  acid  will  produce  the  usual  change. 

The  oily  particles  of  pure  fat  may  be  recognized 
floating  in  the  gastric  contents  or  in  the  aqueous  solu- 
tion of  the  residue  after  evaporating  the  ethereal  extract. 
Butyric  acid  may  also  be  separated  in  the  form  of  drops 
by  adding  small  pieces  of  sodium  chloride. 

Acetic  acid  is  easily  recognized  by  its  odor,  but  it 
may  also  be  detected  by  neutralizing  by  sodium  car- 
bonate the  water}'  residue  after  the  removal  of  the 
ethereal  extract :  then  adding  a  few  drops  of  a  ten  per 
cent,  neutral  ferric  chloride  solution.  A  striking  blood- 
red  color  is  struck,  also  produced  by  formic  acid,  but 
this  is  never  a  constituent  of  gastric  contents. 

Alcohol,  which  is  sometimes  formed  in  the  stomach  in 
intense  yeast  fermentation,  may  be  detected  by  Lieben's 
iodoform-test  applied  to  the  distillate  of  the  stomach 
contents,  as  follows  :  To  a  portion  of  the  distillate  add 
a  small  quantity  of  liquor  potassse,  then  a  few  drops  of 
a  solution  of  iodine  and  iodide  of  potassium  (i,  2,  50). 
If  alcohol  is  present  a  yellowish  precipitate  of  iodoform 
takes  place  slowly.  The  same  precipitate  occurs  with 
acetone,  but  rapidly. 

5.  To  Determine  the  Total  Acidity,  including 
Free  and  Combined  Acids  and  Acid  Salts.-  A  Mohr's 


EXAMINATION    OF    GASTRIC    CONTENTS.  243 

burette  is  filled  with  a  decinormal  *  solution  of  caustic 
soda.  Ten  c.  c.  of  the  filtered  solution  are  placed  in  a 
beaker  and  one  or  two  drops  of  one  per  cent,  alcoholic 
solution  of  phenolphthalein  added  as  an  indicator.  The 
decinormal  solution  is  then  slowly  dropped  from  the 
burette  until  the  red  color  produced  in  the  fluid  by  the 
action  of  the  alkali  on  the  phenolphthalein  no  longer 
disappears  on  shaking.  As  a  rule,  the  total  acidity  of 
the  gastric  contents,  an  hour  after  such  a  meal,  requires 
four  to  six  c.  c.  of  the  decinormal  solution  to  neutralize 
it  in  normal  digestion.  Figures  above  and  below  this 
are  therefore  abnormal.  The  acidity  may  be  expressed 
by  the  number  of  c.  c.  required  to  neutralize  one 
hundred  c.  c.  of  gastric  contents ;  thus,  if  four  c.  c.  were 
required  to  neutralize  ten  c.  c,  there  would  be  forty  per 
hundred,  which  is  also  spoken  of  as  degrees  of  acidity ; 
or,  if  six  c.  c,  60  per  hundred  total  acidity.  Again 
one  cubic  centimeter  of  the  decinormal  solution  is 
equivalent  to  .00365  HCl.  If,  therefore,  the  number 
of  cubic  centimeters  used  to  neutralize  ten  c.  c.  of  the 
solution  be  multiplied  by  .00365  and  again  by  ten,  the 
result  will  be  the  percentage.  Thus,  if  six  c.  c.  of  the 
decinormal  solution  be  used,  the  percentage  will  be 
6  X  .00365  X  10  ^  .219  per  cent.,  within  the  nonxial 
range,  which  is  from  .14  to  .24  per  cent,  in  the  fil- 
trate; if  four  c.  c.  be  used  the  HCl  percentage  will  be 

*  Decinormal  solution  of  soda  ^^  NaH0^4  grams  NaHO  dis- 
solved in  1000  c.  c.  distilled  water.  Each  c.  c.  of  this  solution 
exactly  neutralizes  0.0036  gram  HCl. 


244  PHYSICAL    DIAGNOSIS. 

4  X  -00365  X  10  =  .146,  or  less  than  normal.  The  range 
of  total  acidity  in  the  unfiltered  contents  is  greater  than 
in  the  filtrate,  being  .15  to  .3  per  cent.  This  is  probably 
because  of  the  large  amount  of  combined  acids  in  the 
unfiltered  contents. 

6.  To  Determine  Total  Free  HCl  Quantita- 
tively.— (^)By  Mintz's  method :  Ten  c.  c.  of  the 
stomach  contents  are  titrated  with  the  decinormal  soda 
solution  until  a  response  with  Giinzburg's  reagent  no 
longer  occurs,  testing  a  drop  or  two  of  the  partly  neu- 
trahzed  gastric  contents  with  the  addition  of  each  one- 
tenth  c.  c,  or  fraction  thereof.  Then,  as  one  c.  c. 
decinormal  soda  solution  equals  .0036  HCIO,  we  have 
simply  to  multiply  .00365  by  the  number  of  c.  cs.  used, 
this  by  10,  and  the  result  will  be  the  percentage  re- 
quired. The  last  reading  before  the  disappearance  of 
the  reaction  is  taken  as  the  measure  of  the  HCl.  Thus 
if  the  test  responds  after  5  c.  c.  of  the  decinormal  solu- 
tion have  been  added,  and  does  not  respond  after  5.1 
have  been  added,  the  HCl  in  10  c.  c.  will  be  repre- 
sented by  5  X  -00365  gm. 

(^)  By  Topfer's  method  :  To  ten  c.  c.  of  the  filtered 
contents  add  a  few  drops  of  a  5  per  cent,  alcoholic 
solution  of  dimethyl-amido  azo-benzol.  The  mixture 
turns  a  bright  red  in  the  presence  of  free  HCl.  Titrate 
with  the  decinormal  sodic  solution  until  the  red  turns  to 
a  clear  yellow.     Calculate  as  above. 

7.  To  Determine  Free  HCl,  Organic  Acids, 
and  Acid  Salts. — To  ten  c.  c.  of  the  gastric  filtrate  add 
a  few  drops  of  a  one  per  cent,  aqueous  solution  of  alizarin 


EXAMINATION    OF    GASTRIC    CONTENTS.  245 

(alizarin  monosulphonate  of  sodium)  and  titrate  with 
the  decinormal  sodic  solution  until  the  mixture  assumes 
a  clear  violet  color.  Combined  acids  have  no  effect. 
Alizarin  responds  to  the  alkalinity  which  succeeds  the 
neutralization  of  the  acidity  due  to  free  HCl,  organic 
acids,  and  acid  salts. 

As  the  violet  tint  is  more  or  less  difhcult  for  the 
unpractised  eye  to  recognize,  Topfer  recommends  the 
following  preliminary  tests  : 

(a)  To  five  c.  c.  of  distilled  water  add  two  or  three 
drops  of  the  alizarin  solution.  A  clear  yellow  color 
results. 

(/^)  To  five  c.  c.  of  a  one  per  cent,  solution  of  disodium 
phosphate  add  the  alizarin  solution  as  above.  A  red- 
dish color  with  a  slight  tinge  of  violet  results. 

(c)  Five  c.  c.  of  a  one  per  cent,  solution  of  sodium 
carbonate  when  treated  with  alizarin,  as  above,  gives  a 
clear  violet  tint,  which  is  the  tint  to  be  reached  in  the 
titration.  It  should  be  used  as  a  guide  until  the  eye 
becomes  sufhcientlv  practised.  Where  there  are  no 
free  organic  acids  the  result  of  this  test  represents  free 
HCl  and  acid  salts. 

8.  To  determine  the  combined  HCl,  subtract 
the  acidity  found  by  alizarin  from  that  found  by  the 
phenolphthalein,  /.  e.,    from  (5)  subtract  (7). 

9.  To  determine  the  acidity  due  to  organic 
acids  and  acid  salts,  subtract  the  free  HCl  from  that 
found  by  alizarin,  t.  e.,  from  (7)  subtract  (6). 

10.  To  determine  total  HCl,  free  and  combined, 
to  (6)  add  (8).  Where  free  HCl  is  present  all  the  com- 
bined acid  is  HCl. 


246  PHYSICAL   DIAGNOSIS. 

II.  To  Determine  Acid  Salts. — See  also  p.  237. 
This  may  also  be  done  by  Leo's  method,  which  is  based 
on  the  fact  that  -when  calcium  carbonate  is  added  as  a 
fine  powder  to  gastric  contents,  the  free  and  combined 
HCl  unite  with  the  calcium  carbonate,  forming  calcium 
chloride,  a  neutral  salt,  the  acid  salts  being  unaffected. 
Moreover,  the  calcium  chloride  thus  formed  reacts  with 
the  phosphates  to  form  acid  calcium  phosphate,  which 
requires  twice  the  amount  of  sodium  carbonate  to  neu- 
tralize it  as  the  acid  sodium  phosphate.  Hence  it  is 
necessary  before  each  titration  to  add  an  excess  of 
calcium  chloride  solution. 

Method. — To  fifteen  c.  c.  of  the  gastric  contents  is 
added  a  small  quantity  of  calcium  carbonate,  as  much 
as  will  go  on  the  end  of  a  penknife,  the  mixture  stirred 
and  immediately  filtered  through  a  dry  filter.  The  liber- 
ated carbonic  acid  is  expelled  from  the  filtrate  by  passing 
a  current  of  air  through  it  by  means  of  a  glass  tube. 
Ten  c.  c.  of  this  filtrate  are  then  treated  with  five  c.  c. 
of  a  saturated  solution  of  calcium  chloride  and  titrated 
as  before.  The  result  divided  by  two  represents  the 
acid  phosphates. 

Examination  of  Products  of  Albumin  Digestion. 

The  term //-(^/i'c'/r.f/j- is  applied  to  albumin  digestion, 
in  which  all  proteid  substances  are  converted  into 
peptone.  It  takes  place  partly  in  the  stomach,  but 
probably  even  to  a  greater  degree  in  the  small  intestine. 
In  this  process  the  first  step  is  the  production  of  certain 
substances  intermediate  between  albumin  and  peptone 


EXAMINATION    OF    GASTRIC    CONTENTS.  247 

which  are  called  albumoses  or  proteoses.  Those  which 
are  of  chief  importance  in  the  study  of  gastric  digestion 
are  syntonin  or  acid  albumin,  and  propeptone  or  hemi- 
albumose.  In  the  ordinary  process  of  digestion  with  a 
normal  gastric  juice  some  or  all  of  these  substances 
should  be  present  in  the  stomach  at  the  end  of  an  hour. 
So  far  as  they  are  the  products  of  gastric  digestion  they 
may,  therefore,  be  studied  by  the  aid  of  a  test-meal  and 
removal  of  the  gastric  contents  as  already  described. 

This  digestion  is  accomplished  by  the  agency  of  the 
hydrochloric  acid,  a  proteolytic  ferment  pepsiii,  and  a 
coagulating  ferment  7-ennin,  all  three  secreted  by  the 
glands  of  the  stomach. 

The  secretion  of  HCl  begins  at  once  after  the  intro- 
duction of  food.  It  unites  at  once  with  the  native 
proteids  of  the  food,  forming  acid  proteids,  and  reacts 
with  the  neutral  phosphates  of  the  food,  forming  acid 
salts ;  also  with  the  proenzyme  pepsinogen,  forming 
pepsin,  and  with  the  rennet  zymogen,  forming  rennin. 
A  part  of  the  rennin  is  formed  as  such  in  the  glands. 
The  secretion  of  the  gastric  juice  continues  in  health 
until  all  these  affinities  are  supplied  and  a  certain  amount 
of  HCl  remains  over  as  free  acid.  As  soon  as  this 
appears  the  pepsin  ferment  begins  to  act  on  the  proteids 
and  to  convert  them  into  albumoses  and  peptones,  while 
the  rennet  acts  on  the  casein  of  the  food,  coagulating 
and  converting  it  also  into  soluble  proteid.  Pepsin  acts 
only  in  the  presence  of  HCl,  while  rennin  is  active  in 
acid,  neutral,  or  even  feebly  alkaline  solution. 

Propeptone    and    Peptone. — Propeptone  at    the 


248  PHYSICAL   DL4GN0SIS. 

maximum  of  normal  digestion  should  be  present  only 
in  traces  and  must  be  removed  before  peptone  is  tested 
for,  since  it  responds  to  the  same  test, — the  biuret  test. 
To    remove    propeptone    treat    2    or   3    c.   c.  of  the 
stomach  filtrate  with  an  equal  quantity  of  a  saturated 
solution  of  chloride  of  sodium  and  then  add  one  or  two 
drops  of  strong  acetic  acid.     Propeptone  if  present  is 
thus  precipitated  and  may  be  filtered  out.     To  the  fil- 
trate add  one  c.  c.  of  liquor  potassae,  then  a  few  drops  of 
a  one  per  cent,  solution  of  sulphate  of  copper.     A  purple 
red  color  indicates  the  presence   of   peptone,  and  we 
may  approximately  estimate  its  amount  by  the  intensity 
of  the  biuret  reaction,  provided  we  always  use  the  same 
proportion  of  stomach  contents,  solution  of  potash,  and 
cupric  sulphate.     Should  it   happen   that  a    handsome 
biuret  reaction  is  struck  before  removing  the  propep- 
tone, and  but  a  faint  one  or  none  afterward,  the  pro- 
portion  of   propeptone  is  large  and  of  peptone   small. 
Cahn  has  shown  that  in  dogs,  at  least,  the  quantity  of 
peptone  remains  at  a  certain  percentage,  being  probably 
kept  at  that  figure  by  constant    removal.     Hence    the 
only  index  of  the  rapidity  and  amount  of  albumin  trans- 
formation   is    the    amount    of    propeptone   formed    or 
remaining.     Finally,  Ewald  and  Gumlich  conclude  that 
the  formation  of  tiue  peptone  in  the  human  stojtiach  is 
slight,    albumoses    being    mainly    produced,    the    chief 
transformation  of  which  is  effected  in  the  small  intes- 
tine. 

To  Estimate  the  Activity  of  Proteolysis,  or 
Albumin    Digestion. — By   Ewald's   method,  coagu- 


EXAMINATION    OF    GASTRIC    CONTENTS.  249 

lated  white  of  egg  is  cut  into  thin  slices,  and  out  of 
these  small  discs  are  cut  by  a  cork-borer  or  similar  in- 
strument. These  may  be  prepared  in  quantity  and  kept 
for  use  in  glycerin,  which  should,  however,  be  washed 
off  before  using  the  slices.  An  equal  quantity  of  the 
filtered  gastric  fluid  is  placed  in  four  small  test-tubes 
and  one  or  two  discs  of  albumin  put  into  each.  To  the 
first  nothing  else  is  added,  to  the  second  enough  hydro- 
chloric acid  to  make  a  solution  of  about  *  0.3  to  0.5  per 
cent.  This  is  accomplished  by  adding  two  drops  of 
hydrochloric  acid  to  five  c.  c.  (90  minims)  of  stomach 
contents. 

To  the  third  is  added  a  definite  quantity  of  pepsin, 
about  0.2  to  0.5  gram  [gr.  iij  to  gr.  viiss],  to  the  fourth 
both  hydrochloric  acid  and  pepsin.  The  test-tubes  are 
placed  in  an  incubator  at  about  100°  Fahr.,  and  from 
time  to  time  examined  with  a  view  to  learning  how  far 
the  liquefaction  of  the  discs  of  albumin  has  proceeded. 
The  rate  of  this  will  inform  us  whether  digestion  would 
have  occurred  without  the  addition  of  anything,  or 
whether  acid  or  pepsin  or  both  were  necessary.  We 
will  learn,  also,  whether  by  adding  more  hydrochloric 
acid  we  have  made  the  acidity  excessive. 

It  must  be  remembered,  however,  that  after  the  pep- 
tone has  reached  a  certain  percentage,  its  further  pro- 


*  The  difference  between  the  strength  of  the  acetic  acid  of  the 
German  Pharmacopoeia  (25  per  cent,  of  the  anhydrous  acid),  in- 
tended by  Evvald,  and  that  of  the  U.  S.  P.  (32  per  cent.)  is  not 
sufficient  to  necessitate  a  change  of  proportion. 


250  PHYSICAL   DL4GN0SIS. 

duction  is  retarded,  or  even  suspended,  so  that  there 
may  be  an  apparently  slow  reaction  with  even  a  very 
active  gastric  juice.  Ewald  happily  reminds  us  that  all 
laboratory  attempts  to  imitate  digestion  are  defective  in 
the  important  respect  that  with  our  test-tubes  and  flasks 
we  can  neither  imitate  absorption  on  the  one  hand,  nor, 
on  the  other,  allow  for  the  onward  movement  to  the  in- 
testines of  the  gastric  contents,  two  important  functions 
by  which  the  stomach  strives  to  maintain  a  fairly  uni- 
form degree  of  concentration  of  its  contents. 

The  Action  of  Rennet,  the  Milk-coagulating 
Element  of  the  Natural  Gastric  Juice. — The 
simplest  method  of  estimating  the  action  of  rennet  is 
that  of  Leo.  To  ten  c.  c.  of  raw  milk  are  added  two  to 
five  drops  of  stomach  contents.  Raw  milk  is  used  be- 
cause it  coagulates  ten  times  more  rapidly  than  boiled 
milk,  while  neutralization  is  unnecessary  because  of  the 
relatively  small  quantity  of  gastric  juice  used.  The 
mixture  is  placed  in  the  warm  chamber  at  100°  F.,  and 
coagulation  should  take  place  in  from  one  minute  to 
several  hours.  The  characteristic  coagulation  of  rennet 
is  a  cake  of  casein  floating  in  clear  serum,  while  acids 
produce  lumpy  and  flaky  masses. 

The  rennet-ferment,  or  enzyme  (lab  ferment),  does 
not  exist  primarily  as  such  but  as  a  rennet  zymogen  or 
proenzyme,  which  itself  has  no  action  on  milk,  but  is 
converted  into  rennet  by  the  action  of  any  acid,  as 
hydrochloric,  or  of  warm  chloride  of  calcium.  This 
may  be  shown  as  follows  :  If  the  spontaneous  coagu- 
lating action  of  gastric  juice  on  milk  be  destroyed  by 


EXAMINATION    OF    GASTRIC    CONTENTS.  25 1 

neutralization  by  an  alkaline  carbonate,  this  property 
may  be  restored  by  digesting  with  dilute  hydrochloric 
acid  or  by  the  addition  of  a  five  per  cent,  solution  of 
calcium  chloride.  While  fasting  and  at  the  beginning 
of  digestion,  zymogen  only  is  present  in  the  stomach, 
but  later  both  it  and  the  ferment  are  found.  An  acid 
reaction  for  the  curdling  action  of  rennet  is  not  abso- 
lutely necessary. 

Digestion  of  Starch  and  Sugar.— It  is  well 
known  that  during  digestion  starch  is  converted  into 
grape  sugar,  and  cane  sugar  is  converted  into  invert 
sugar — a  mixture  of  cane  and  grape  sugar.  This  action, 
commenced  in  the  mouth  by  the  ptyalin  of  saliva,  is 
continued  to  a  less  degree  so  long  as  the  acidity  is  slight 
(.01  per  cenl.  for  HCl,  .i  or  .2  per  cent,  for  lactic,  .4 
per  cent,  for  butyric)  in  the  stomach,  and  is  finished  in 
the  small  intestine  by  the  trypsin  of  the  pancreatic 
juice.  As  in  albumin  digestion  there  are  intermediate 
substances  between  albumin  and  peptone,  so  between 
starch  and  grape  sugar  there  are  similar  intermediate 
products.     The  order  is  as  follows  : 

(i)  Starch,  (2)  Dextrins  (Erythrodextrin,  Achroodex- 
trin),  (3)  Maltose,  (4)  Dextrose  =  grape  sugar. 

Starch  is  recognized  by  the  deep  blue  color  struck 
with  iodine  or  Lugol's  solution  (iodine  i,  iodide  of 
potassium  2,  distilled  water  200),  and  the  reaction 
grows  less  vivid  as  the  starch  is  converted.  Of  the 
dextrins,  erythrodextrin  strikes  not  a  blue  but  a  purple 
color,  while  solutions  of  achroodextrin,  maltose,  and 
grape  sugar  take  on  only  the  yellow  color  of  the  iodine 


2^2  PHYSICAL   DLA.GNOSIS. 

solution.  Where  a  mixture  of  these  substances  occurs, 
the  first  few  drops  of  the  iodine  solution  produce  no 
color  at  all,  or  only  a  transitor}'^  one,  being  taken  up  by 
the  dextrose  and  maltose,  while  the  addition  of  more 
iodine  strikes  the  purple  of  erythrodextrin  or  blue  of 
starch. 

If,  therefore,  amylaceous  transformation  has  pro- 
gressed normally  in  the  mouth  and  stomach,  so  much 
starch  should  be  changed  into  achroodextrin,  maltose, 
or  dextrose  that  the  addition  of  small  quantities  of 
Lugol's  solution  does  not  strike  the  characteristic  color. 
If,  however,  the  blue  or  purple  reactions  appear,  con- 
version has  not  been  sufficiently  rapid  into  maltose,  the 
principal  product  of  gastric  conversion,  the  change  into 
dextrose  being  completed  in  the  small  intestine.  This 
may  be  due  either  to  a  deficiency  of  ptyalin  or  a  too 
rapid  production  of  acid  in  the  stomach.  From  such 
event  we  might  also  infer  a  hyperacidity  of  the  gastric 
juice. 

To  Determine  the  Rapidity  of  Absorption 
from  the  Stomach.  — Penzoldt's  method  is  that  gen- 
erally followed.  A  capsule  containing  iodide  of  potas- 
sium (.1  gram  or  gr.  iss)  is  swallowed,  being  first  care- 
fully wiped  to  remove  any  adherent  particles.  The 
appearance  of  the  iodide  in  the  saliva  indicates  that 
absorption  has  taken  place  from  the  stomach.  To 
determine  this,  starch  paper  is  first  prepared  by 
moistening  with  starch-paste  and  drying.  Then,  after 
the  salt  is  swallowed,  a  piece  of  the  paper  is  moistened 
every  five  minutes  with  the  saliva,  and  the  moistened 


EXAMINATION   OF   GASTRIC   CONTENTS.  253 

spot  touched  with  fuming  nitric  acid.  As  soon  as  the 
iodine  appears  in  the  saliva  the  characteristic  blue 
reaction  is  struck. 

When  adsorption  is  normal  this  reaction  tisnally  takes 
place  in  ten  or  fifteen  minutes,  but  where  absorption  is 
abnormally  delayed,. the  reaction  is  also  delayed  half  an 
hour  or  more,  or  it  may  not  occur  at  all. 

To  Test  the  Motor  Function  of  the  Stomach. 
— Three  methods  are  practised.  First,  reixiove  the 
gastric  contents  six  to  seven  hours  after  the  ingestion  of 
a  large  meal,  or  two  and  a  half  hours  after  an  Ewald 
breakfast,  and  note  the  amount  of  solid  substance 
remaining.     The  stomach  should  by  this  time  be  empty. 

Second,  salol  is  administered  and  the  product  of 
its  lysis  sought  for  in  the  urine.  Third,  a  definite 
quantity  of  ohve  oil  is  introduced  into  the  empty 
stomach  and  the  remnant  unabsorbed  is  withdrawn 
at  the  end  of  two  hours.  The  second,  though  not 
without  drawbacks,  is  preferred.  Salol  is  composed  of 
phenol  and  saHcylic  acid,  into  which  it  is  broken  up 
by  the  action  of  the  pancreatic  juice,  but  not  by  the 
acid  gastric  contents.  Salicyluric  acid,  a  product  of 
decomposition  of  salicylic  acid,  appears  in  the  urine 
forty  to  sixty,  or  at  most  seventy-five,  minutes  after 
taking  one  gram  (15  grs.)  of  salol  when  gastric  peri- 
stalsis is  normal.  Salicyluric  acid  is  readily  detected  in 
the  urine  by  the  violet  color  produced  on  the  addition 
of  neutral  ferric  chloride  solution.  The  method  em- 
ployed is  to  place  a  drop  of  urine  on  a  piece  of  filter- 
paper  and  bring  in  contact  with  this  a  drop  of  a  ten  per 


254  PHYSICAL    DIAGNOSIS. 

cent,  ferric  chloride  solution.  The  edge  of  the  drop 
will  strike  a  violet  color  in  the  presence  of  a  mere  trace 
of  salicyluric  acid. 

The  objection  to  the  salol  test  is  that  the  decompo- 
sition of  the  salol  may  be  delayed  by  an  undue  acidity 
of  the  gastiic  contents  discharged  into  the  duodenum. 
But  practically  this  is  found  not  to  be  a  serious  drawback, 
tolerably  constant  results  being  obtained  by  Ewald  and 
Sievers.  To  meet  this  objection,  however,  Huber  sug- 
gested that  the  outside  limit  of  excretion  of  salicyluric 
acid  fails  to  appear  in  the  urine  after  the  ingestion  of 
a  gram  (15  grs.)  of  salol.  This  sliould  be  at  the  end  of 
tiuenty-foiir  or  thi?-ty  hours.  If,  therefore,  it  is  con- 
tinued after  this,  peristalsis  must  be  slow. 

In  Klemperer's  oil  test  too  c.  c.  {2)}'^  ozs.)  of  olive 
oil  are  introduced  into  the  stomach  by  the  stomach 
tube  after  the  stomach  is  thoroughly  washed  out.  Two 
hours  later  the  stomach  is  aspirated,  and  if  there  is 
motor  sufficiency  the  remnant  of  oil  should  be  a  mini- 
mum. If  any  decided  quantity  remains  peristalsis  is 
slow. 

To  Determine  the  Capacity  of  the  Stomach. 
— The  capacity  of  the  stomach  in  health  is  from  1600 
to  1700  c.  c.  (say  from  3  to  ■^yi  pints).  Its  normal 
limits  and  deviations  therefrom  can  usually  be  deter- 
mined by  percussion.  This  is  rendered  easier  by 
distending  the  stomach  with  gas  or  liquid,  as  by  having 
the  patient  drink  a  glass  of  water  just  before  the  exami- 
nation, or,  as  oiiginally  suggested  by  Frerichs,  by 
taking  in  rapid  succession  the  two  portions  of  a  Seidlitz 


THE    ROENTGEN    RAY    IN   DIAGNOSIS.  255 

powder — tartaric  acid  and  sodium  bicarbonate — or  a 
glass  of  soda  water.  A  better  way  is  to  iniiate  the 
stomacli  with  air,  as  suggested  by  Runeberg,  by  means 
of  the  double  bulb  of  a  spray  appratus.  This  should 
be  done,  if  possible,  in  connection  with  the  use  of  the 
tube  for  some  other  purpose,  as  removing  the  stomach 
contents  after  a  test-meal.  In  fact,  the  simplest  way  is 
to  fill  the  stomach  with  the  washing-out  fluid  and  meas- 
uring the  quantity  thus  used.  The  air  inflation  is  pre- 
ferable to  gas,  because  if  any  excess  is  introduced  it 
passes  oul  alongside  of  the  tube,  which  is  not  the  case 
with  carbonic  acid  gas,  which  excites  rather  a  spasmodic 
contraction  of  the  cardiac  orifice. 


THE    ROENTGEN    RAY    IN    DIAGNOSIS. 

The  discovery  in  1895  by  Prof.  Roentgen,  of  Wurz- 
burg,  of  the  pecuHar  ray  to  which  he  gave  the  name  of 
X-ray,  at  once  gave  promise  of  important  possible 
results  in  diagnosis.  These  rays  were  believed  to  ema 
nate  from  the  cathode  when  induced  electric  currents 
were  passed  through  a  vacuum-tube  (Crooke's  tube). 
Recent  studies  by  Prof.  Trowbridge  give  reason  to 
beheve  that  such  rays  emanate  from  the  anode  as  well, 
but  are  less  powerful.  Their  potency  is  shown  in  their 
ability  to  pass  through  solid  objects.  They  are  not  sub- 
ject to  reflection  or  refraction,  and  give  rise  to  fluores- 
cence and  phosphoroscence.     The  latter  is,  of  course, 


256  PHYSICAL   DIAGNOSIS. 

best  seen  in  a  dark  room,  while  fluorescence  ordinarily 
ceases  to  exhibit  light  in  the  dark. 

The  energy  of  the  X-rays  is,  however,  manifested  in 
its  penetrating  power,  since  by  their  aid  we  can  see 
through  timbers  a  foot  thick  and  see  the  beating  of  the 
human  heart  through  the  flesh. 

The  examination  is  accomplished  as  follows,  in  a 
dark  room :  The  body  is  placed  between  a  Crooke's 
tube  and  a  photographic  plate  placed  in  a  box,  under 
which  circumstances  the  soft  parts  appear  dark  on  the 
negative  and  the  denser  parts  appear  light.  The  posi- 
tives made  from  this  exhibit  the  opposite,  the  bones 
being  dark  and  the  soft  parts  light.  In  lieu  of  the 
photographic  plate  the  fluoroscope  is  used  to  study  the 
effect  of  the  rays.  The  advantages  of  the  Roentgen 
rays  have  been  greatest  in  connection  with  surgery,  but 
they  may  also  be  applied  to  medical  diagnosis. 

In  the  thorax,  it  is  especially  in  the  diagnosis  of  en- 
largements of  the  heart,  of  pericarditis,  and  of  aneurism 
of  the  aorta  and  calcareous  blood-vessels  that  the  appa- 
ratus is  available.  Emphysema  of  the  lungs,  tumors  in 
their  substance,  pleuritic  effusions,  and  calcareous  plates 
may  also  be  recognized.  A  striking  demonstration  is 
the  motion  of  the  heart  and  lungs. 

In  abdommal  organs  this  mode  of  diagnosis  has  been 
of  most  service  in  recognizing  stones  in  the  kidney  and 
ureters,  although  it  has  not  always  been  successful. 
The  same  is  true  of  biliary  and  vesical  calculi.  Not 
much  help  has  as  yet  been  secured  in  the  diagnosis  of 
diseases  of   the  abdominal  organs ;    the    organs    them- 


THE   ROENTGEN   RAY   IN   DIAGNOSIS.  257 

selves  cannot  be  differentiated.  Those  penetrable  by 
metallic  sounds,  such  as  the  oesophagus  and  stomach, 
may  be    more    successfully  explored.     So,  too,  foreign 


Fig.  46.—"  Seal  Fin  "  Deflexion  of  the  Hand  in  a  Case  of  Protracted 
Arthritis  Deformans. 

From  a  photograph  with  the  Roentgen  ray,  showing  also  erosion  and  dislocation 
oi  joints. 


258  PHYSICAL   DIAGNOSIS. 

bodies  accidentally  introduced,  such  as  coins,  or  jack- 
stones,  have  been  well  located. 

Diseases  of  the  bones  and  joints  have  been,  after 
the  last-named  objects,  most  satisfactorily  investigated. 
Bony  outgrowths  can  be  easily  outlined.  The  appended 
figure  shows  fairly  well  the  changes  in  a  case  of  rheu- 
matoid arthiitis,  which  may,  by  this  means,  be  differen- 
tiated from  those  of  gout. 

Caries  of  the  vertebr?e  and  the  changes  of  rickcfs  have 
been  similarly  recognized,  and  it  is  more  than  likely,  as 
the  subject  is  further  developed,  that  important  aids  to 
diagnosis  will  be  further  added. 


THE  MAKING  OF  AN  AUTOPSY.* 

Previous  to  section  a  general  survey  of  the  body 
should  be  made  with  a  view  to  noting  marks,  scars,  state 
of  the  body  as  to  obesity  or  emaciation,  and  degree  of 
rigor  iiiorfis,  post  mortem  lividity,  and  decomposition. 

A  position  to  the  right  of  the  body  is  usually  more 
convenient  for  the  right-handed  examiner,  while  the  left 
side  is  more  convenient  to  one  who  is  left-handed.  To 
the  ambidexter  it  is  indifferent  on  which  side  he  stands. 


*  The  directions  here  given  are  for  an  autopsy  for  clinical  pur- 
poses, and  not  for  the  medico-legal  investigation,  which  is  much 
more  elaborate.  The  general  plan  adopted  is  that  laid  down  by 
Virchow  in  his  little  book  on  "  Post-mortem  Examinations,"  which 
the  writer  has  followed  for  many  years  with  great  satisfaction, 


THE    IMAKING    OF    AN    AUTOPSY.  259 

The  appended  directions  imply  that  the  knife  is  held  in 
the  right  hand 

The  first  incision  is  made  with  a  strong,  broad  hand- 
led knife  by  a  sweeping  traction  movement  down  the 
median  hne  from  the  suprasternal  notch  to  the  symphysis 
pnbis,  passing  to  the  left  of  the  mnbilicus.  Then  the 
skin  and  adjacent  muscles  of  the  thorax  are  cut  back 
and  the  section  through  the  abdominal  walls  carefully 
completed,  avoiding  perforation  of  the  intestines.  The 
muscles  are  also  separated  from  the  edge  of  the  thorax 
and  the  abdominal  walls  laid  back,  so  as  to  expose  as 
much  as  possible  the  abdominal  viscera  before  opening 
the  thorax.  This  is  done  in  order  to  preserve  the 
natural  relations  of  the  abdominal  viscera  to  each  other 
and  to  the  diaphragm,  relations  which  are  altered  as 
soon  as  the  thorax  is  opened  by  the  removal  of  the 
sternum  and  attached  cartilages.  An  inspection  of  the 
abdominal  contents  is  therefore  first  made,  the  absence 
or  presence  of  fluid  or  abnormality  noted,  without^  how- 
ever, as  yet  removing  or  making  any  section  of  the  ograns. 

Next  the  cartilages  are  cut  through  near  their  junc- 
tion with  the  ribs  from  the  2d  downward;  this  is  often 
done  on  each  side  by  one  sweep  of  the  knife  in  the 
hands  of  the  skilled  sectionist,  if  the  subject  is  not  too 
old.  If  not  complete,  the  section  of  the  cartilages  and 
muscular  interspaces  should  then  be  thoroughly  com- 
pleted, by  the  bone  forceps,  if  necessary.  The  clavicle 
and  ist  rib  should  be  disarticulated  from  the  sternum, 
bearing  in  mind  that  the  articulation  is  an  oblique  one, 
and    that    it    can    readily    be    found    by   grasping    the 


2  6o  PHYSICAL   DIAGNOSIS. 

clavicle  and  moving  it.  Or,  if  it  is  preferred,  the  knife 
may  be  drawn  through  the  middle  of  the  2d  cartilage, 
when  it  will  strike  the  junction  between  the  first  and 
second  bones  of  the  sternum,  leaving  the  manubrium, 
with  the  articulation  of  the  clavicle  and  ist  rib,  intact. 
This,  however,  restricts  the  space  over  the  origin  of  the 
great  vessels  rather  inconveniently,  and  the  former 
method  is  to  be  preferred  unless  the  latter  is  necessi- 
tated for  some  special  reason.  The  sternum  should  be 
raised,  beginning  with  the  tip,  and  the  muscles  and 
other  tissues  shaved  close  to  its  under  surface.  This  act 
uncovers  the  mediastinum  and  opens  the  two  pleural 
sacs,  without,  however,  incising  the  pericardium,  if  the 
section  has  been  successful.  The  superfluous  integu- 
ment thus  dissected  off  should  be  folded  over  the  cut 
edges  of  the  ribs  to  protect  the  hand  against  these  rough 
edges. 

The  pleural  sacs  should  now  be  examined  by  insert- 
ing the  hand  between  the  lungs  and  the  ribs  and  the 
diaphragm,  with  a  view  of  finding  adhesions  or  fluid, 
and  the  latter,  if  present,  should  be  removed  and 
measured.  Outgrowths  or  inequalities  of  the  pleural 
surfaces,  pulmonary,  costal,  and  diaphragmatic,  should 
be  looked  for.  The  lungs  should,  however,  be  left  as 
yet  in  situ. 

The  pericardium  should  then  be  opened,  and  the 
position  of  the  heart  obser\-ed.  If  an  abnormal  amount 
of  fluid  is  present  in  the  sac,  it  should  be  removed  and 
measured.  The  external  appearance  of  the  heart,  its 
size,  shape,  and  consistence,  should  be  noted ;  also  the 


THE    MAKING    OF    AN    AUTOPSY.  26 1 

state  of  fulness  of  the  superficial  vessels,  the  amount  of 
superficial  fat,  adhesions,  or  other  abnormality. 

The  heaj't  should  then  be  opened  in  situ,  with  the  pur- 
pose of  examining  the  quantity  and  quality  of  blood  in 
the  separate  cavities  and  the  size  of  the  orifices.  In 
thus  opening  the  organ  it  is  held  in  the  left  hand  with 
the  index  finger  pressed  well  under  and  against  the  base, 
so  that  the  ventricles  project  laterally.  It  is  then 
rotated  to  the  left  until  the  rigid  border  comes  into 
view,  being  easily  recognized  by  the  relative  thinness  of 
the  wall  here  as  compared  with  that  of  the  left  ventricle 
on  the  other  side  of  the  septum.  At  the  right  border, 
close  to  the  base,  the  knife  is  deeply  thrust  into  the  right 
ventricle,  and  drawn,  to  the  apex.  With  the  heart  still 
thus  held,  the  right  aiiricle  is  incised  midway  between 
the  entrances  of  the  two  vense  cavae.  The  blood  is  then 
removed  from  the  right  auricle,  its  quantity  and  quality 
observed.  The  index  and  middle  fingers  of  the  left  hand 
are  now  passed  from  the  auricle  through  the  tricuspid 
orifice  into  the  right  ventricle.  Then  the  blood  is  re- 
moved from  the  right  ventricle.  The  right  auriculo- 
ventricular  orifice  in  the  adult,  if  normal,  should  re- 
ceive three  fingers,  the  index  and  middle  finger  of  the 
left  hand  so  far  separated  that  the  index  finger  of  the 
right  may  be  passed  up  between  them  from  the  right 
ventricle. 

To  make  the  openings  for  the  left  side,  the  apex  of  the 
heart  is  drawn  up  to  the  left,  and  placed  in  the  left 
hand  in  such  a  way  that  the  fingers  encircle  it  at  the 
base.     Pressure  is  now  made  so  that  the  wall  of  the  left 


262  PHYSICAL    DIAGNOSIS. 

ventricle  bulges  out  a  little  and  separates  itself  from  the 
septum,  when  the  incision  is  made  behind  the  base 
through  the  middle  of  the  external  wall  into  the  left 
ventricle  and  out  at  the  apjex.  For  the  left  auricle  the 
incision  begins  at  the  left  superior  pulmonary  vein,  and 
ends  in  front  of  the  base  usually  indicated  by  the 
coronary  vein,  which  should  not  be  injured. 

The  blood  is  now  removed  from  the  left  cavities,  and 
the  size  of  the  auriculo-ventricular  orifice  determined. 
Here  we  have  to  consider  the  contraction  of  the  ventri- 
cle which  closes  the  orifice,  and  we  have  to  gradually 
overcome  this  contraction,  when  we  may  introduce  the 
three  fingers  named  with  less  facility  than  into  the 
tricuspid  orifice,  the  mitral  being  4.5  cm.  (1.8  in.)  in 
diameter  as  against  5  cm.  (2  in.)  for  the  tricuspid. 
The  fingers  should  be  very  carefully  introduced  and 
withdrawn,  so  that  no  abnormal  vegetations  or  coagulae 
are  removed,  for  the  valves  have  not  yet  been  examined. 

The  next  step  is  the  removal  of  the  heart.  This  is 
done  by  thrusting  the  index  finger  of  the  left  hand  into 
the  left  ventricle  and  the  thumb  into  the  right  through 
the  openings  made.  The  heart  is  then  raised  and  the 
vense  cavse,  the  pulmonary  artery,  aorta,  and  pulmonary 
veins  severed  as  far  as  possible  from  the  heart. 

The  orifices  of  the  aorta  and  pulmonary  artery  are  then 
examined  with  a  view  to  discovering  changes  in  their 
walls  or  lumen.  The  hydrostatic  test  is  then  applied  for 
the  sufficiency  of  the  aorta  and  pulmonary  valves  by 
pouring  water  into  each  vessel  while  the  heart  is  freely 
suspended.     Previously,  however,  all  coagula  should  be 


THE   MAKING    OF   AN   AUTOPSY.  263 

carefully  removed  from  the  orifices  and  ventricles.  The 
plane  of  the  orifice  should  also  be  exactly  horizontal,  and 
for  this  two  hands  are  necessary  to  accomplish  the  proper 
support,  and  the  water  must  be  poured  in  by  a  second 
person.  The  aorta  should  also  be  cut  again,  short 
enough  to  enable  one  to  see  from  above  the  state  of  the 
valves.  Care  should  be  taken  to  avoid  wounding  the 
coronary  arteries,  for  if  this  accident  happens,  the  water 
may  run  off  into  them  and  give  the  impression  of  insuf- 
ficiency when  it  does  not  exist. 

There  is  no  hydrostatic  or  other  test  available  to  show 
the  sufficiency  of  the  auriculo-ventricular  valves. 

We  are  next  ready  to  open  the  ventricles  and  explore 
the  interior,  including  the  valves.  The  heart  is  placed 
on  a  board  or  table,  as  nearly  as  possible  in  its  position 
in  the  body.  A  long  pair  of  scissors  is  the  most  satis- 
factory instrument  for  this  purpose.  For  the  right  ven- 
tricle one  blade  is  introduced  at  the  center  of  the  right 
ventricular  incision  previously  made  and  carried  well 
over  toward  the  left  side  between  the  left  anterior  and 
posterior  leaflets  of  the  pulmonary  valve,  care  being 
taken  to  pass  above  the  insertion  of  the  anterior  papil- 
lary muscle  of  the  tricuspid  valve  with  its  chordae 
tendinese. 

To  display  the  left  ventricle  is  more  difficult.  Intro- 
duce one  blade  of  the  scissors  at  the  apex  close  to  the 
septum,  and  while  drawing  the  pulmonary  artery  to  the 
right,  cut  close  to  the  ventricular  wall  until  the  portion 
of  the  left  dog's-ear  which  overlaps  the  ventricle  is 
reached.     If  we   pass   too  far  to   the  left  we  will  cut 


264  PHYSICAL   DIAGNOSIS. 

through  the  right  border  of  the  base  of  the  mit?-al  valve, 
which  corresponds  with  the  right  border  of  the  left 
auricle ;  if  too  far  to  the  right  we  cross  the  pulmonary 
orifice  and  may  cut  through  the  valves  of  the  pulmonary 
artery. 

The  auricles  can  be  further  opened  by  cutting  with 
the  scissors  on  the  right  between  the  openings  of  the 
vena  cavje,  and  on  the  left  between  those  of  the  pul- 
monary veins. 

The  adult  heart  'weighs  in  health  in  the  male  fifty  to 
sixty  years  old  about  335  grams  (xi.8  oz.,  avoirdupois')  ; 
in  the  female,  295  grams  (10.44  oz.). 

The  average  thickness  of  the  wall  oi  the  left  ventricle 
is  T.6  to  1.7  cm.  (^^  to  2/<  in  )  ;  of  the  right  ventricle 
.4  to  .6  cm.  (1/6  to  14^  in.) 

The  lungs  are  now  removed,  their  surface  examined 
for  emphysematous  distension  or  subpleural  deposits, 
and  then  incised  longitudinally  with  a  view  to  the  dis- 
covery in  their  interior  of  tubercular  infiltration,  cavi- 
ties, changes  in  the  bronchi,  etc.  The  right  lung  can 
always  be  differentiated  from  the  left  by  its  three 
lobes. 

The  lungs  weigh,  in  the  male,  the  right,  859.5  grams 
(30.3  oz.)  ;  the  left,  8ri.6  giams  (28.6  oz.)  ;  in  the 
female,  the  right,  552  grams  (19.48  oz.)  ;  the  left,  296 
grams  (10.2  oz.). 

For  the  examination  of  the  pharynx,  larynx,  ceospha- 
gus,  and  thyroid  gland,  the  central  incision  should  be 
carried  up  to  an  inch  below  the  chin.  The  first  three 
should  be  slit  up  with  the  enterotome,  the  last  dissected 


THE  MAKING  OF  AN  AUTOPSY.  265 

off.  The  thyroid  varies  a  good  deal  in  weight,  usually 
about  30  grams  or  i>^  oz.  These  organs  and  a  portion 
or  all  of  the  tongue  can  be  removed  by  dissecting  up 
under  the  skin  and  then  making  a  transverse  cut,  thns 
obviating  opening  the  skin  on  the  neck. 

The  abdominal  organs  are  now  examined  in  the  fol- 
lowing order : 

1.  The  omentum. 

2.  The  spleen,  which  is  longitudinally  incised.  The 
organ  in  health  weighs  about  176  grams  (6.23  oz.). 

3.  The  left  and  right  kidney,  with  their  suprarenal 
capsules  and  ureters  ;  the  kidney  being  stripped  of  its 
capsule  and  longitudinally  incised. 

The  adult  kidney  weight,  in  the  male,  113.5  to  170 
grams  (4  to  6  oz.)  ;  in  the  female  a  little  less,  113.5  to 
156  grams  (4  to  5}^  oz.).  The  suprarenal  capsules, 
4  grams  to  8  grams  (60  to  120  grains). 

4.  The  bladder,  prostate  gland,  vesiculse  seminales, 
urethra.  The  prostate  weighs  in  health  about  3 1  grams 
(i^oz.). 

5.  Testicles,  spermatic  cord,  and  penis.  The  testis 
with  the  epididymis  weighs  about  24.5  grams  (J^  to  ^ 
oz.). 

6.  Vagina,  uterus.  Fallopian  tubes,  ovaries,  parame- 
tria. 

The  weight  of  the  uterus  differs  greatly  at  different 
ages.  Thus,  according  to  Robert  Boyd's  table,  in  11 
girls  from  fourteen  to  twenty,  the  minimum  weight  was 
17.01  grams,  the  maximum  70.87  grams,  average  29.48 
grams  (1.04  oz.)  ;  in  47  women  between  twenty  and 
thirty,   the  minimum  was   21.26  grams,  the  maximum 


2  66  PHYSICAL    DIAGNOSIS. 

120.48  grams,  average  49.04  grams  (1.73  oz. )  ;  in.  79 
women  between  thirty  and  forty,  the  minimum  was 
14.17  grams,  the  maximum  127.57  grams,  average  56.13 
grams  (1.98  oz.)  ;  of  the  ovaries  3.9  to  6.5  grams  (60 
to  100  grains) . 

7.  The  rectum. 

8.  The  duodenum.,  portio  intestinalis  of  the  ductus 
communis  choledochus. 

9.  Stomach.     Capacity  i  to  1.5  h"tres  (2  to  3  pints). 

10.  Hepato-duodenal  ligament,  gall-ducts,  venae 
portae,  gall-bladder,  liver. 

The  stomach  and  duodenum,  under  ordinary  circum- 
stances, should  be  examined  /;/  situ.  The  duodenum 
should  be  opened  first,  its  contents  examined  above  and 
below  the  biliary  papilla.  The  latter  should  be  ex- 
amined, its  contents  expressed,  and  its  patulousness 
determined  by  pressing  gently  on  the  gall-bladder. 
Finally,  the  common  bile  duct  should  be  slit  up.  The 
vena  cava  should  be  examined,  and  not  until  then 
should  the  liver  be  removed  and  examined.  Sections 
should  be  made  through  the  organ  horizontally,  from 
right  to  left,  to  displa}  its  interior.  The  gall-duct  should 
not  be  probed,  as  a  duct  essentially  closed  may  thus  be 
opened. 

The //?'<?;■  weighs  in  health  from  about  1247.4  grams 
(2^  lbs.)  in  the  female  to  1569.7  grams  (3^  lbs.). 

11.  The  examination  of  the  panci-eas  naturally  fol- 
lows the  stomach  and  duodenum  and  liver,  and  after  it 
the  coeliac  (semilunar)  ganglia. 

The  organ  weighs  70  to  108  grams  (2js  to  35^2  oz.). 


THE  MAKING  OF  AN  AUTOPSY.  267 

12.  Mesentery  with  glands,  vessels. 

13.  Small  and  large  intestines.-  These,  after  the 
examination  of  the  stomach  and  duodenum  /;/  situ, 
should  be  removed,  placed  on  a  board  or  in  water,  and 
laid  open,  care  being  taken  on  opening  the  small  intes- 
tines to  keep  on  the  line  of  the  mesentery.  If  possi- 
ble, water  should  be  allowed  to  run  through  the  intes- 
tines before  opening  them.  The  solitary  glands  and 
glands  of  Peyer  should  be  carefully  examined. 

14.  Retro-peritoneal  lymphatic  glands,  receptaculum 
chyli,  aorta,  vena  cava  inferior. 

Examination  of  the  brain. — The  scalp  is  divided  by 
an  incision  across  the  top  of  the  head  from  ear  to  ear, 
and  reflected  backward  and  forward,  noting  the  presence 
or  absence  of  extravasated  blood.  The  skull-cap  is  now 
sawn  through,  better  by  two  angular  cuts  so  as  to  re- 
move a  wedge-shaped  piece,  care  being  taken  not  to 
wound  the  dura  mater.  To  this  end  the  chisel  and 
hammer  are  used  to  break  through  the  internal  table. 
But  it  is  sometimes  impossible  to  avoid  injuring  the 
dura,  and  it  may  even  be  necessary  to  cut  it  through  in 
consequence  of  the  difficulty  in  separating  it  from  the 
skull-cap.  The  thickness  of  the  cranial  bones,  their 
internal  surfaces,  and  the  condition  of  the  diploe  are 
examined;  also  the  external  surface  of  the  dura  mater 
and  the  state  of  the  sinuses.  The  brain  is  then  re- 
moved, severing  the  cord  as  low  as  possible  through  the 
foramen  magnum,  and  effusion  at  the  base  of  the 
cranium  looked  for.  The  dura  is  separated  and  the 
appearance  of  the  arachnoid  and  pia  noted.     Also  that 


268  PHYSICAL    DIAGNOSIS. 

of  the  large  arteries  at  the  base ;  atheroma  is  especially 
sought.  In  health  the  visceral  arachnoid  presents  a 
faint,  opalescent  appearance,  and  any  turbidity  or 
opaqueness  beyond  this  points  to  meningitis.  The  state 
of  the  blood-vessels  in  the  pia  is  carefully  examined,  and 
the  presence  or  absence  of  effusion  noted.  As  the  pia 
mater  is  drawn  aside,  the  blood-vessels  which  dip  down 
between  the  sulci  into  the  fissure  of  Sylvius  are  exam- 
ined, especially  their  sheaths. 

The  pia  being  removed,  the  surface  of  the  brain  is 
examined,  the  depth  of  the  sulci,  flattening  of  the  con- 
volutions, and  any  marked  deviations  in  their  airange- 
ment  noted. 

The  dissection  of  the  drain  is  now  commenced, 
beginning  with  the  opening  of  the  lateral  ventricles. 
This  is  done  after  drawing  apart  the  halves  of  the 
cerebrum,  by  an  incision  one  millimetre  (J-  inch)  on 
each  side  of  the  median  line  in  the  corpus  callosum 
directly  downward,  when  the  middle  portion  of  the 
lateral  ventricle  is  reached  at  the  depth  of  two  or  three 
millimetres  (yV  to  ^  inch).  The  anterior  and  posterior 
cornua  of  the  lateral  ventricle  are  then  opened  by  hori- 
zontal incisions  from  this  point  into  the  anterior  and 
posterior  lobes  of  the  brain.  Thus  the  lateral  ventricles 
are  exposed  throughout  their  extent,  and  their  contents, 
the  state  of  their  walls,  and  the  venous  plexuses  exam- 
ined ;  also  the  septum  lucidum,  with  its  contained  5th 
ventricle. 

The  septum  is  then  seized  from  behind  the  foramen 
of  Monro  and  the  scalpel  pushed  in  front  of  the  fingers 


THE  MAKING  OF  AN  AUTOPSY.  269 

through  this  foramen,  and  the  corpus  callosum  cut 
through  obliquely  upward  and  forward,  and  then  these 
parts  (the  corpus  callosum,  septum  lucidum,  and  fornix) 
are  carefully  detached  from  the  velum  interpositum  and 
choroid  plexus,  which  are  examined  as  to  the  state  of 
their  vessels  and  tissue. 

The  handle  of  the  scalpel  is  then  passed  from  the 
front  under  the  velum,  which  is  thus  detached  from  the 
pineal  body  and  corpora  quadrigemina,  which  are  ex- 
amined. The  3d  ventricle  is  then  exposed.  Finally, 
the  corpora  quadrigemina  and  the  cerebellum  are 
divided  as  far  as  the  aqueduct  of  Sylvius  and  the  4th 
ventricle. 

The  hemispheres  of  the  cerebrum  and  cerebellum  are 
now  sliced  by  transverse  incisions  rather  than  longitu- 
dinal ones,  because  in  this  way  the  parts  can  again  be 
more  easily  united  if  desired,  with  a  view  to  determine 
the  relation  of  parts  or  the  seat  of  lesions. 

The  optic  thalami  and  corpora  striata  are  cut  hy  fan- 
shaped  incisions  radiating  from  the  peduncle  of  the 
cerebrum. 

The  adult  brain  of  the  male  weighs  on  an  average 
about  1400  grams  (49)^  oz.  avoird.),  of  the  female 
1245  grams  (44^  oz.  avoird.).  The  cerebrum  alone 
weighs  1244  grams  (43  oz.  15  dr.)  in  the  male,  and 
1098  grams  (38  oz.  12  dr.)  in  the  female;  the  cerebel- 
lum 148^  grams  (5  oz.  4  dr.)  in  the  male,  in  the 
female  137  grams  (4  oz.  i2j^  dr.).  The  pons  and 
medulla  oblongata  weigh  28  grams  (isH  ^^0  ^^  *^^ 
male,  and  in  the  female  28.8  grams  (i  oz.  ^  dr.). 


270  PHYSICAL   DIAGNOSIS. 

The  removal  of  the  spinal  cord  is  a  laborious  opera 
tion.  The  spinal  canal  is  opened,  preferably  from 
behind,  by  dissecting  back  the  skin  from  the  median 
line  and  sawing  upon  each  side  of  the  spines  of  the 
vertebrae,  slanting  the  saw  30°  from  the  median  line  at 
the  side  of  the  spinal  canal,  or  by  using  a  double  saw. 
The  cord  when  removed  is  carefully  examined  as  to  its 
membranes,  and  transverse  incisions  made  at  intervals 
of  a  half-inch  or  less,  leaving  the  membrane  intact  at 
one  spot,  so  that  the  pieces  are  all  held  together  like 
the  leaves  of  a  book. 

The  spinal  cord  weighs  37.2  grams  (i  oz.  5  dr.) 
in  the  male,  and  35.43  grams  (i  oz.  4  dr.)  in  the 
female. 

The  Eye  is  reached  by  chiseling  off  the  roof  of  the 
orbit.  The  posterior  half  of  the  eye,  which  is  commonly 
all  that  is  needed,  can  be  removed  by  seizing  the  sclera 
with  forceps  and  cutting  around  the  eyeball  with  sharp 
scissors.  It  should  be  done  quickly,  because  in  this  way 
the  retina  can  be  kept  from  folding.  The  anterior  half 
of  the  eyeball  is  to  be  held  in  place  by  a  plug  of  cotton 
dipped  in  ink  or  other  dark  substance. 

The  Ear. — The  middle  ear  can  be  exposed  by  chip- 
ping off  the  petrous  portion  of  the  temporal  bone  which 
covers  it. 

The  Nasopharynx  can  be  exposed  by  chiseling  off 
that  part  of  the  base  of  the  skull  lying  above  it. 

It  is  always  desirable  to  take  to  an  autopsy  three  or 
four  wide-mouth  bottles  of  about  two  ounce  capacity 
containing  preservative  fluids  in  which  to  place   small 


ORDER    OF    EXAMINATION   OF   PATIENT.  27 1 

pieces  of  tissue  intended  for  subsequent  examination. 
In  one  of  these  should  be  placed  95  per  cent,  alcohol,  in 
another  70  per  cent,  alcohol,  in  a  third  Mullein's  fluid. 
The  fourth  may  be  reserved  for  unexpected  purposes. 
Miiller's  fluid  is  especially  used" for  nervous  tissues.  It  is 
composed  of  bichromate  of  potassium,  2.5  grams;  sul- 
phate of  sodium,  i  gram;  water,  100  c.  c.  If  to  this  is 
added  corrosive  sublimate,  5  grams,  and  glacial  acetic 
acid,  5  c.  c,  we  have  Zenker's  .^\M,  which  is  even 
better. 


ORDER   OF   EXAMINATION   OF   PATIENT. 

Name,  nativity,  and  residence. 
Age. 

Occupation.     This  is  often  carelessly  stated,  and  should 
be  carefully  investigated,  including  changes  of  occu- 
pation and  especially  occupation  just  previous  to  ill- 
ness. 
Social  condition  [married  or  single]. 

Habits  of  patient  [/.  e.,  as  to  mode  of  living,  temper- 
ance in  eating  and  drinking]. 
Family  history. 

Health  of  parents,  brothers,  sisters,  and  children. 
History  of  previous  illnesses. 

The  diseases  experienced  by  the  patient  before  the 
present  illness  [/.  e.,  diphtheria,  scarlet  fever, 
typhoid  fever,  rheumatism,  malaria,  pneumonia, 
pleurisy,  venereal  disease,  etc.]. 


272  PHYSICAL   DLA.GNOSIS. 

Historj'  of  present  illness  or  of  pre^dous  attacks  of  same. 

1.  Ask  how  long  patient  has  been   sick.     Ascertain 
this  definitely  b)'  suitable  questions. 

2.  Get  the  symptoms  in  regular  order  from  the  be- 
ginning to  the  present. 

Condition  on  coming  under  treatment  or  admission  to 
hospital, — that  is,  the  symptoms  of  which  the  patient 
complains  at  such  time. 

Physical  examination.      [Patient  stripped.] 

1.  General  appearance  of  patient. 

2.  Chest:   Inspection,    palpation,    mensuration,    per- 
cussion, auscultation. 

3.  Abdomen. 

4.  Special  parts. 


FRENCH    WEIGHTS    AND    ]MEASURES. 


273 


METRIC  OR  FRENCH  WEIGHTS. 

Grain.        Troy  Grain. 


Milligram, 

.001  = 

■01543 

Centigram, 

.01     = 

•15433 

Decigram, 

.1       = 

1-5433 

Av.  07i7ice. 

Av.  Pound. 

Gram, 

I          = 

15.43316  = 

.03528  = 

.0022047 

Decagram, 

10 

= 

.3528    = 

.022047 

Hectogram, 

100 

= 

3.52758  = 

.2204737 

Kilogram, 

TOGO 

= 

35.2758    = 

2.204737 

Myriogram, 

lOOOO 

= 

22.04737 

Quintal, 

lOOOOO 

= 

220.4737 

METRIC  OR  FRENCH  LINEAL  MEASURE. 


Meter.     U.  S.  Inch.             Feet. 

Millimeter,* 

.001  =       .03937  =            .00328 

Centimeter,t 

.01     =       .3937    =            .03280 

Yard. 

Decimeter, 

.1      =     3.937      =            .32807  = 

.10936 

Meter, 

I          =  39.3685     =          3.2807     = 

1.0936 

Decameter, 

10                               =        32.807      = 

10.936 

Mile. 

Hectometer, 

100                               =      328.07        =- 

109.26       ^ 

.0621347 

Kilometer, 

1000                               ^     3280.7          = 

1093.6         = 

.6213466 

Myriameter, 

loooo                                  ^  32807             = 

10936            = 

6.213466 

*  Nearly  585  inch.                       t  Full  | 

-  inch. 

NDEX. 


ABDOMEN,  auscultation  of,  197 
inspection  of,  199 
palpation  of,  201 
percussion  of,  204 
physical  examination  of,  197 
Absorption,  to  determine  rapidity  of, 

252 
Acetic  acid,  test  for,  242 
Acid,  butyric,  241 

hydrochloric,  determination  of,  244 
salts,  to  determine,  246 
Acidity  of  gastric  contents,  determina- 
tion of  total,  242 
Acids,  fatty,  241 

organic,  determination  of,  240 
Acute  bronchitis,  83 

miliary  tuberculosis,  95 
Adventitious  sounds,  78 
^gophony,  78 

Albumin  digestion,  products  of,  248 
Alcohol,  test  for,  242 
Amphoric  breathing,  73 
resonance,  59 
voice,  78 
Anatomy,  medical,  of  thorax,  15 
Aneurism,  thoracic,  188 
of  the  innominate,  196 

pulmonary  artery,  196 
subclavian,  196 
Aortic  diastolic  murmur,  135 
murmurs,  126 

obstruction,  or  stenosis,  162 
regurgitation,  or  insufficiency,  168 
stenosis  and  insufficiency,  168 
systolic  murmur,  133 
Apoplexy,  pulmonary,  loi 
Arterial  murmurs,  abnormal,  142 
normal,  141 
tension,  low,  149 

prolonged,  148 
Asthma,  spasmodic,  88 
Auscultation,  61 


Auscultation  of  the  normal  lung,  65 

voice,  75 
Autopsy,  making  of,  258 

Bacillus  of  cholera,  staining  of,  234 
of  diphtheria,  staining  of,  232 
of  pneumonia,  staining  of,  230 
of  tubercle,  staining  of,  227 
Bell  tympany,  59 
Biermer's  change  of  note,  58 
Blood,  examination  of,  212 

corpuscles,  counting  of,  212 
films,  preparation  of,  222 
ordinary  microscopic  examination 
of,  212 
Boas's  test  for  HCl,  239 
Borders  of  the  lungs,  23 
Breathing  sounds,  abnormal  modifica- 
tions of,  68 
Bronchial  breathing,  66 

changes  in,  73 
varieties  of,  73 
Bronchitis,  acute,  83 

capillary,  8 
chronic,  84 
Bronchophony,  normal,  76 
Broncho- pneumonia,  100 
Bruit  de  diable,  144 

Cancer  of  lung,  103 
Cardiac  valves,  topography  of,  122 
Cardiograph  in  diagnosis,  152 
Cardio-respiratory  murmur,  138 
Catarrhal  phthisis,  89 

pneumonia,  100 
Cavernous  breathing,  73 
Chest,  regions  of,  11 
Cholera,  staining  of  bacillus  of,  234 
Churning  or  water-wheel  sound,  138 
Cirrhosis  of  lung,  102 
Coin-clinking,  59 
Collapse  of  lung,  102 


(27s) 


276 


INDEX. 


Congenital  defects  of  heart,  173 
Consumption,  89 
Cracked-pot  sound,  60 
Crackling  rales,  80 
Curschmann's  spirals,  226 

Danger,  relative,  of  different  forms  ol 

valvular  heart  disease,  176 
Delafield's  hematoxylin,  223 
Determination    of   free    HCl,  organic 

acids,  and  acid  salts,  244 
Diaphragm  phenomenon,  31 
Dilatation  of  the  heart,  183 
Diphtheria,  staining  of  bacillus  of,  232 
Dorsal  test  for  pericardial  effusion,  180 
Dulness.  percussion,  41 
positive,  of  liver,  41 
relative,  of  liver,  47 
Duration  of  percussion  sounds,  45 

Embolic  pneumonia,  loi 
Emphysema,  circumscribed,  no 

interlobular,  of  lung,  88 

pulsating,  no 

vesicular,  of  lungs,  87 
Endocarditis,  acute,  179 
Eosinophile  cells,  226 
Examination  of  patients,  order  of,  271 
Exocardial  sound,  137 

False  jugular  pulse,  170 
Fatty  infiltration,  184 

metamorphosis,  185 
Fibroid  phthisis,  94 
Flint's  murmur,  133 
Foetal  heart-beat,  000 

free  acid  test  for,  237 
Frequency  of  different  forms  of  valvular 

heart  disease,  174 
Friction  sound,  81 

pericardial,  137 
pleural,  81 
Functional  murmurs,  138 

Gastric  contents,  chemical  examination 

of,  235 
General  considerations,  9 
Gerhardt's  change  of  note,  56 
Gonococcus,  284 

Giinzburg's  solution  test  for  HCl,  238 
Gurgling,  80 

Haemic  murmurs,  138 
Haemoglobin,  to  measure,  220 
Heart,  absolute  dulness  of,  118 

anatomical  relations  of,  113 

auscultation  of  normal,  160 

congenital  defects,  173 

dilatation  of,  183 


Heart,  fatty  infiltration  of,  184 
metamorphosis,  185 

percussion  boundaries  of,  116 

physical  examination  of,  113 

relative  dulness  of,  118 
I  weight  of,  264 

Heart-sounds,   abnormal  modifications 
of,  124 

impurity  of,  137 

intensity  of,  125 

mechanism  of,  120 

reduplication  of,  124 

time  of,  123 
Hemorrhagic  infarct,  loi 
Hippocratic  succession,  83 
Hydrochloric    acid,   determination   of, 

238 
Hydropericardium,  181 
Hypertrophy,  general,  of  the  heart,  183 

of  the  left  ventricle,  182 

of  the  right  ventricle,  183 

Inspection,  26 
Intensity  of  sounds,  40 
Intestines,  percussion  of,  208 

Jugular  pulse,  false,  170 

Lactic  add,  determination  of,  240 
Left  ventricle,  hypertrophy  of,  182 
Leo's  carbonate  of  calcium,  test  for,  238 
Litten's  sign,  31 
Liver,  weight  of,  266 
Lung,  cancer  of,  103 

cirrhosis  of,  94 

collapse  of,  102 

compressed,  103 

normal,  auscultation  of,  65 
Lungs,  outline  of,  23 

emphysema,  85 

interlobular  emphysema,  88 

Measure,  metric  or  French  lineal,  373 
Mensuration,  26 
Metallic  tinkling,  82 
Metamorphosing  breath-sound  of  Seitz, 

74 
Mitral  diastolic  murmur,  131 

insufficiency,  156 

insufficiency  and  stenosis,  162 

murmurs,  128 
Mitral  obstruction  or  stenosis,  159 

presystolic  murmur,  131 

systolic  murmur,  128 
Motor  function  of  stomach,  253 
Mucous  rale,  80 
Murmurs,  aortic,  133 

arterial,  normal,  141 

abnormal,  142 


277 


Murmurs,  cardiac,  126 

cardio-respiratory,  138 

functional,  138 

mitral,  129 

organic,  128 

pulmonary,  136 

tricuspid,  136 

vascular,  141 

venous,  143 
Medical  anatomy  of  the  thorax,  15 
Myocarditis,  i85 
Myocardium,  diseases  of,  181 
Myositis,  acute,  182 

Normal    breathing    sounds,    modifica- 
tions of,  68 
chest,  percussion  of,  45 

QEdema,  pulmonary,  102 
Ovarian  cysts,  percussion  of,  209 

Palpation,  32 
Pectoriloquy,  77 
Peptone,  247 
Percussion,  34 

auscultatory,  36 

of  bladder,  209 

dulness,  41 

of  normal  chest,  45 

pitch  and  duration,  42 

respiratory,  38 

sounds,  abnormal,  of  lung,  52 
attributes  of,  39 
duration,  45 
intensity  of,  39 
quality  of,  39 

ol  stomach,  206 

topographical,  45 
Pericarditis,  180 
Phonendoscope,  38 
Phthisis,  catarrhal,  89 

fibroid,  94 

tubercular,  89 
Physical  signs  in  valvular  disease,  156 
Pitch  of  sounds,  39 
Placental  murmur,  143 
Pleurisy,  acute,  103 

chronic,  107 

latent,  108 
Pneumonia,  96 

acute  croupous,  96 

catarrhal,  100 

embolic,  loi 

lobar,  96 

lobular,  100 
Pneumococcus,  staining  of,  230 
Pneumothorax,  iii 
Praecordium,  115 
Presystolic  murmur,  131 


Propeptone, 247 
Pulmonary  apoplexy,  loi 

murmur,  136 

obstruction,  or  stenosis,  172 

oedema.  102 

regurgitation,  173 

tuberculosis,  89 
Pulse  tracing,  normal,  145 
Pulsus  bigeminus,  151 
trigeminus,  151 

Quality  of  sounds,  39 

Rales,  78 

crackling,  80 

dry,  79 

moist,  79 

mucous,  80 
Reduplication  of  heart  sounds,  124 
Regions  of  the  chest,  11 
Rennet,  action  of,  250 
Resonance,  amphoric,  59 

tympanitic,  55 

vesicular,  40 

vesiculo-tympanitic,  43 
Right  ventricle,  hypertrophy  of,  183 

Seitz's  metamorphosing  breath-sound, 

74 
Shapes  of  chest,  27 
Skoda's  sign,  53 

Sphygmograph  in  diagnosis,  144 
Spleen,  percussion  borders,  205 
Sputum,  examination  of,  226 
Staining  of  bacilli  of  tubercle,  227 
cholera,  234 
diphtheria,  232 
pneumococcus,  130 
Starch  and  sugar,  digestion  of,  254 
Stomach,  capacity  of,  254 
percussion,  206 
succession,  211 
hippocratic,  83 

Thoracic  aneurism,  188 
Topfer's  test  for  HCI,  239 
Trachea,  bifurcation  of,  26 
Tricuspid  obstructiou,  or  stenosis,  171 

murmur,  136 

regurgitation,  136 
Tubercle  bacilli,  staining  of,  227 
Tubercular  phthisis,  89 
Tuberculosis,  acute  miliary,  95 

pulmonary,  89 
Tympany,  41-55 
Typhoid  fever,  Widal's  test  for,  224 

Ufielmann's  test,  240 


278 


INDEX. 


Valves,  cardiac  topography,  122 
Valvular  defects,  relative  frequency  of, 
174 
gravity  of,  174 
Vascular  murmurs,  141 
Venous  hum,  144 

murmurs,  128 
Vesicular  murmur,  56 

breathing,  66 

murmur,  changes  in,  68 

resonance,  40 
Vesiculo-tympanitic  resonance,  43-53 


Vocal  resonance,  diminished,  78 

normal,  75 
Voice,  abnormal  modifications  of  the 
auscultated,  77 
auscultation  of,  75 
whispering,  76 

Weights,  metric  or  French,  273 
\Miispering  voice,  76 
Widai  test  for  tj'phoid  fever,  224 
Wintrich's  change  of  note,  56 


•WMMBMiW^VIIMIIPiPWiiP 


tiiiiMMiiil 


